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upper eval > exam 2 > Flashcards

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)

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2
Q

3 articulations at elbow

A

humeroulnar, humeroradial, and proximal radioulnar

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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.

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4
Q

humeroradial joint

A

capitellum of humerus articulates with radial head. radial fossa accommodates the margin of radial head during flexion.

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5
Q

proximal radioulnar joint

A

pivot joint. pronation/supination

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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.

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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.

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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

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9
Q

Radial collateral ligament

A

resists elbow varus deformation. Origin near axis for elbow flex/ext so fibers are right throughout ROM

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10
Q

Lateral UCL

A

Primary lateral elbow stabilizer.

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11
Q

Annular ligament

A

Inserts on the anterior and posterior margins of lesser (radial) semilunar notch. Maintains radial head in contact with ulna

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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

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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

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14
Q

Brachioradialis

A

Origin: lateral supracondylar ridge of humerus. Insertion: lateral aspect of radial styloid process. Elbow flexion with forearm in neutral position

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15
Q

Brachialis

A

Insertion: ulnar tuberosity and coronoid process. Elbow flexion when forearm is pronated

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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

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17
Q

Anconeous

A

Origin: lateral epicondylitis of humerus. Insertion: lateral aspect of Olecranon and posterior ulna. Assists triceps with elbow extension.

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18
Q

Supinator

A

Orig: lateral epicondyle, annular ligament, radial collateral lig and supinator crest of ulna. Insertion: lateral proximal 1/3 of radius

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19
Q

Pronator teres

A

Origin: common flexor tendon @medial epicondyle and medial coronoid process. Insertion: lateral surface of radial shaft.

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20
Q

Flexor pronators common origin and list

A

Medial epicondyle. Pronators teres, flexor carpi radialis/ulnaris, flexor digitorum superficialis/profundus, palmaris longus

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21
Q

Extensor-supinators. Common origin and list

A

Lateral epicondyle of humerus. Supinator, extensor carpi radialis longus/brevis/ulnaris, extensor digitorum.

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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.

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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

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24
Q

Ulnar artery.

A

Originates at radial head continues medially down forearm.

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25
Q

Median nerve.

A

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.

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26
Q

Cubical fossa

A

Superior border= imaginary line between medial/lateral epicondyles. Medial border= pronators teres muscle. Lateral border = brachioradialis. Contains brachial artery and median nerve

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27
Q

Ligament of Struthers

A

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.

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28
Q

Radial nerve

A

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.

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29
Q

Ulnar nerve.

A

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.

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30
Q

tennis elbow

A

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.

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31
Q

angiofibroblastic degeneration

A

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

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32
Q

pathologic staging of tendinosis (4)

A

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?)

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33
Q

phases of tendinosis pain (7)

A

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.

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34
Q

Clinical management of tennis elbow

A
  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.
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35
Q

epicondylosis/algia treatment options

A

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)

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36
Q

Golfer’s elbow

A

medial epicondylitis. AKA medial tennis elbow.

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37
Q

medial epicondylitis

A

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)

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38
Q

DDx for medial elbow pain in throwing athlete. (source of pathology to possible diagnosis)

A
  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.
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39
Q

OCD

A

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

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40
Q

elbow’s peripheral nerves

A

median, ulnar, radial

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41
Q

injuries associated with median nerve

A

(C6-8, T1) high medial nerve entrapment syndrome. Volkmann’s ischemic contracture. Carpal tunnel syndrome

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42
Q

injuries associated with ulnar nerve

A

(C7-C8, T1) Cubital tunnel syndrome=proximal elbow. Tunnel of Guyon=at wrist

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43
Q

injuries associated with radial nerve

A

(C5-C8, T1) associated with radial fracture

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44
Q

common musculoskeletal injuries of elbow

A

dislocations, fractures, avulsions, chondral injuries, Volkmann’s ischemic contracture

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45
Q

dislocations at elbow

A
  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
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46
Q

supracondylar fx

A
  • 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.
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47
Q

Gartland Classification system for ___ fx’s.

A

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.

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48
Q

among children how many growth plates are active w/in elbow joint capsule?

A

3 (humerus, ulna, radius)

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49
Q

humerus ossification centers

A
  1. lateral epicondyle, medial epicondyle, capitellum &lateral part of the trochlea, medial trochlea.
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50
Q

ulnar ossification center

A
  1. olecranon.
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51
Q

Salter-Harris classification of___.

A

of growth plate fxs. 5 types.

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52
Q

Salter Harris Type I

A

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.

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53
Q

Salter Harris Type II

A

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.

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54
Q

Salter Harris Type III

A

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.

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55
Q

Salter Harris Type IV

A

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.

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56
Q

Salter Harris Type V

A

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.

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57
Q

Avulsion fxs

A

medial epicondyle (by flexors), lateral epicondyle (by extensors), biceps tuberosity on medial, posterior radius (by?). Occurs when tendons/ligaments pull pieces off.

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58
Q

chondral fxs.

A

radial head (compression from valgus force), Capitellum of humerus, olecranon fossa of ulna, coronoid fossa of ulna. Worst case scenario:OCD.

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59
Q

Volkmann’s ischemic contracure

A

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.

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60
Q

DDx of lateral elbow pain

A

Lateral epicondylitis. entrapment of radial nerve (Radial Tunnel S). Radiocapitellar joint degenerative changes. Cervical spine problems.

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61
Q

Lateral epicondylitis

A

“tennis” ECRB= primary muscle involved w/condition. Extensor digitorum (“communis”) involved 30% of time. ECRL and ECU=lesser involvement.

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62
Q

entrapment of radial nerve

A

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.

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63
Q

radiocapitellar joint degenerative changes

A

dr will order elbow xrays to rule out degenerative joint changes.

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64
Q

cervical spine probs.

A

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.

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65
Q

tennis vs little league vs golfers.

A

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.

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66
Q

DDx of medial elbow pain

A

medial epicondylitis, ulnar nerve injury, medial collateral ligament injury, degenerative changes in medial elbow joint.

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67
Q

medial epicondylitis

A

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

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68
Q

ulnar nerve injury

A

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.

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69
Q

medial UCL injury.

A

tenderness over UCL, anterior posterior or transverse bundle. valgus stress test at 30 degrees flexion is positive.

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70
Q

pathomechanics of medial elbow pain in pitchers

A

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.

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71
Q

UCL reconstructive surgery

A

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.

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72
Q

today’s tommy john.

A

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.

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73
Q

degenerative changes in the medial elbow joint.

A

xrays to R/O bone spurs, osteochondral defects, and/or osteoarthritis. AGE=huge factor

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74
Q

bony articulations of shoulder girdle

A

sternoclavicular, acromioclavicular, glenohumeral. and scapulothoracic (ST, not a true bone to bone joint!)

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75
Q

sternoclavicular joint and movements

A

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.

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76
Q

Sternoclavicular disk

A

fibrocartilage disk (meniscus) between bony articulating surfaces. increases joint congruence and absorbs force.

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77
Q

sternoclavicular joint capsule and ligaments

A
  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
Q

Acromioclavicular joint and motions

A

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
Q

AC joint capsule and ligaments

A

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
Q

coracoclavicular lig

A

primary restraint that prevents superior translation of clavicle on the acromion. Trapezoid portion (anterior and lateral). Conoid portion (more medial and posterior)

81
Q

Glenohumeral joint

A

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
Q

glenoid labrum

A

concave fibrocartilage that surrounds periphery of glenoid fossa. provides increased depth or curvature of fossa and stabilizes joint

83
Q

GH joint capsule

A

ligamentous capsule surrounds GH joint. in anatomical neutral position capsule is taut superiorly and loose anteriorly and inferiorly.

84
Q

structures that form the roof of the GH joint

A

Coracoid process, acromion process, coracoacromial ligament.

85
Q

GH major ligaments and functions.

A

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
Q

IGHLC and functions

A

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
Q

scapulothoracic articulation

A

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
Q

voluntary anatomical motions of ST articulation 6

A

elevation/depression, retraction/protraction (add/abd) upward/downward rotation.

89
Q

prime movers for upward rotation of ST artic.

A

three muscles combine to create a force couple for upward rotation: serratus anterior, upper trap, lower trap

90
Q

ST depression, protraction and downward rotation muscle

A

Pectoralis minor

91
Q

scapulohumeral rhythm

A

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
Q

GH static stabilizers

A

=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
Q

GH dynamic stabilizers

A

=muscles of the shoulder girdle:

  1. rotator cuff
  2. scapular stabilizers
  3. position and power muscles.
94
Q

Rotator cuff muscles

A

SupraspinatusInfraspinatusTeresminorSubscapularis. eccentrically contract to slow down arm.

95
Q

SITS function

A

supraspinatus: initiates abduction, humeral head compression
infraspinatus: external rotator
teres minor: external rotator
subscapularis: role in internal rotation and poss some extension

96
Q

rotator cuff and ___ form force couple

A

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
Q

scapular stabilizers

A

levator scapula, rhomboids, traps (upper, middle, and lower), serratus anterior, and pectoralis minor

98
Q

position and power muscles of shoulder

A

deltoid, pectoralis major, and latissimus dorsi

99
Q

deltoid position and power role

A

gross positioning of arm in space. 3 functional components: anterior= flexion, ABduction, horizontal flexion. Middle= ABduction. Posterior= extension, ABduction, horizontal extension.

100
Q

pectoralis major and latissimus dorsi position and power roles

A

provide power during overhead activities. primary internal rotators of humerus

101
Q

long thoracic motor deficits (C5,6,7)

A

winged scap (serratus anterior)

102
Q

suprascapular motor deficits (C5, 6)

A

difficulty initiating ABduction (supraspinatus)

103
Q

Axillary motor and sensory deficits C5,6

A

difficulty with ABduction (deltoid).

sensory d: Lateral side of arm below point of shoulder

104
Q

musculocutaneous C5,6,7 motor and sensory deficits

A

motor d: very weak elbow flexion (biceps and brachialis)

sensory d: lateral forearm.

105
Q

Radial C5-T1 motor and sensory deficits

A

motor d: drop wrist (ECRL, ECRB, ECU)

sensory d: posterolateral arm; dorsum of hand

106
Q

median C5-T1 motor and sensory deficits

A

motor:weak pronation and wrist flexion (pronators and FCR)
Sensory: radial portion of forearm.

107
Q

ulnar C7,8, T1

A

motor: clawing of fingers (interossei, lumbricals)
sensory: ulnar 1/2 of ring finger + little finger

108
Q

SC joint

A

least commonly injured joint of shoulder girdle. dislocation= exceedingly rare=1-3% of all dislocations at shoulder.

109
Q

of SC joint dislocations

A

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
Q

SC joint sprains and treatment

A

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
Q

SC joint injuries surgical treatment

A

mediastinal compression from a posterior SC dislocations is one of the few indications for surgical intervention.

112
Q

SC joint degenerative disorders

A

osteoarthritis, septic arthritis, rheumatoid arthritis, sternoclavicular hyperstosis

113
Q

AC injuries MOI

A

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
Q

AC joint ligamentous injuries classification system

A

Rockwood’s 6,

115
Q

Rockwood’s classification of __ joint ligamentous injuries.

A

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
Q

AC joint non op treatment

A
  • adhesive strapping
  • sling/bandage
  • Kenny Howard Brace and harness
  • figure 8 bandage
  • sling and pressure dressing
  • abduction traction and suspension in bed
  • casting
117
Q

AC joint op treatment

A

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
Q

Fxs of clavicle

A

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
Q

Allman fx classification scheme of ____

A

group 1=middle 1/3rd of clavicle; most common. Group II= distal (lateral 1/3rd) Group III= medial 1/3rd.

120
Q

Neer fx classification of ___

A

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
Q

brachial plexus stingers/burners

A

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
Q

Seddon Nerve injury classification

A

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
Q

nerve injuries in the upper extremity

A
  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
Q

natural incidence of rotator cuff tears ranges from

A

5-26.5%. PTRCTs are more frequent. incidence of rotator cuff injury is age dependent, with FTRCTs rare in patients under 40.

125
Q

Pathoanatomy of RCTs

A

Outlet impingement- type 1 acromion= “flat”. 2=curved. 3= hooked.
Secondary impingement

126
Q

Special tests for RCT

A

Full/empty can test.

127
Q

Full can test

A

75% accurate for supra spinsters tears. Less painful to patient than empty can

128
Q

Empty can test

A

70% accurate for supraspinatus tears.

129
Q

Is shoulder pain location useful in locating the site of the RCT?

A

NO. pain is poorly correlated with actual location of tear.

130
Q

In patients with RC tendinopathy:

A

Motion pain more common than rest/night pain. Lateral and anterior portions of shoulder=most common locations of pain, regardless of RCT site.

131
Q

Supraspinatus test (can tests) most accurate when interpreted as

A

+ with MMT less than grade 5.

132
Q

External rotation strength (infraspinatus) is most accurate with

A

with MMT less than grade 4+.

133
Q

Lift off test is most accurate for subscapularis tears with

A

MMT less than grade 3

134
Q

MRI or MRA for RCTs?

A

MRA. magnetic resonance angiography

135
Q

Diagnostic classification system for RCTs based on___. And categories

A

Tear size. Small tear= 3-5 cm.

massive tear = >5 cm.

136
Q

Surgical techniques for RC repair.

A

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
Q

Overhead athlete

A

Large ROM. Repetitive microtrauma. Muscular fatigue leads to altered kinematics which leads to injury.

138
Q

Shoulder impingement syndrome

A

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
Q

Neer’s outlet impingement.

A

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
Q

Type 1 acromion process

A

Flat. Normal subacromial space. Minimal impingement risk. 6%

141
Q

Type II acromion process.

A

Curved. Slightly decreased subacromial space, increased risk of impingement. 42%

142
Q

Type III acromion process.

A

Significantly decreased subacromial space. Highest risk of impingement. 51%

143
Q

Type IV

A

Hooked with spurs.

144
Q

GH non-outlet impingement

A

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
Q

Primary impingement.

A

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
Q

Secondary impingement.

A

Younger, typically overhead athletes. Subtle GH instability. Decreased humeral head control. Surgery addresses excessive GH laxity.

147
Q

Primary GH impingement surgical options

A

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
Q

secondary GH impingement surgical options

A

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.

149
Q

glenohumeral laxity vs instability

A

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

150
Q

directions of GH instability

A

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

151
Q

multidirectional GH instability

A

primary anterior= pain when arm abducted + ER position
primary posterior=pain w/ pushing heavy objects
primary inferior= pain w/carrying heavy objects @side

152
Q

LigMaster Arthrometer

A

permits measurement of anterior, posterior, and inferior GH joint laxity/stability to the nearest .1 mm, current cost $20 k

153
Q

Masten’s classification

A

AMBRI or TUBS

154
Q

AMBRI

A

Atraumatic, Multidirectional, Bilateral, Rehabilitation (responds well to), Inferior capsular shift

155
Q

TUBS

A

Traumatic, Unidirectional instability (ant. most common), Bankart lesion usually occurs, Surgery usually required, usually anterior capsular shift technique + Bankart repair= >90% success rate.

156
Q

TUBS lesion

A

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

157
Q

Bankart lesion and reverse

A

torn anterior labrum. Reverse=torn posterior labrum.

158
Q

Hill-Sachs lesion and reverse

A

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.

159
Q

circle concept of stability

A

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.

160
Q

History of Posterior shoulder dislocations.

A

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

161
Q

pathologies caused by posterior shoulder dislocations

A

posterior capsular instability
reverse Bankart lesion
Avulsion fx of lesser tuberosity of humerus
Reverse Hill-Sachs lesion

162
Q

treatment of recurrent posterior shoulder instability

A

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.

163
Q

MDI

A

multidirectional instability. definition=symptomatic GH inst. in more than 1 direction. while definition is straightforward, diagnosis and clinical management of MDI are not.

164
Q

Wynne-Davis hypermobility criteria

A

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

165
Q

MDI typical px history

A

age-10-30 yrs. bilateral in 11-13% patients. on clinical exam, px dislocate in ant, inf, and post directions. chief complaint= pain

166
Q

MDI pathology

A

excessively lax inferior capsular pouch. weakness of rotator cuff, scapular stabilizer muscles. proprioceptive deficit(s) (upper weight bearing and balancing)? general ligamentous laxity

167
Q

clinical management of AMBRI and MDI patients

A

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.

168
Q

freq of GH dislocations in USA; and percent of direction.

A

19 k first time traumatic injuries per yr. 25 k total first time and recurrent dislocations per yr.
98%anterior! 2 %posterior

169
Q

key ligaments of GH joint

A

superior GH lig, middle GH lig, Inferior GH lig complex.

170
Q

pathoanatomy of Bankart lesion.

A

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.

171
Q

Atraumatic (aka “subtle”) GH instability

A

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

172
Q

subtle instability:capsular and ligamentous creep deformation

A
  • 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
173
Q

key clinical GH laxity tests

A

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

174
Q

BC micro-instability is so subtle, your clinical exam

A

may be more sensitive than radiographs/MRI.

175
Q

clinical laxity tests for subtle GH instability

A

Load and Shift (anterior/post drawer), Sulcus sign, Feagin test.

176
Q

key anatomical features of glenoid labrum

A

site of attachment for GH ligs and long head of biceps

blood supply to peripheral region closest to bone; inner rim is relatively avascular

177
Q

SLAP lesion

A

superior labrum tear, anterior to posterior.

178
Q

glenoid anterior labrum injury epidemiology

A

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

179
Q

glenoid posterior labrum injury epidem.

A

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)

180
Q

SLAP epid.

A

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

181
Q

Snyder classification system

A

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.

182
Q

Special tests for SLAP lesions

A

active compression (O’Brien’s test), Anterior slide test, Compression-rotation (grind test)

183
Q

scapular stabilizers and rotators

A

traps (3), rhomboid major, rhomboid minor, levator scapulae, serratus anterior,

184
Q

scapular extrinsic musculature

A

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.

185
Q

roles of scapula during overhead movements (5)

A
  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.
186
Q

pathomechanics associated with scapular dyskinesis (3)

A

muscular imbalance sequelae, excessive scapular protraction sequelae, and loss of stable scapular base sequelae.

187
Q

muscular imbalance sequelae

A
  • 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
188
Q

excessive scapular protraction sequelae

A

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.

189
Q

loss of stable scapular base sequelae

A 
No stable origin for muscle actions.
Decreased dynamic stabilization by the rotator cuff muscles.
Exacerbates scapular protraction.
Associated secondary impingement.
Associated labral pathology.
190
Q

cascade of events associated with scapular dyskinesis

A 
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
191
Q

objective measurements of scapular dyskinesia

A

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.

upper eval (9 decks)

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