Low Yield Flashcards
Where do the trapezoid and conoid ligaments insert on the clavicle?
Trapezoid- 3.0cm from distal end
Conoid- 4.5cm from distal end
What portion of the AC ligament is strongest?
Superior
2nd is posterior
Where is the most common location for an os acromiale?
Junction of the meso- and meta- acromion;
60% are bilateral
Treated with bone grafting and second stage acromioplasty
What are shoulder exam findings of impingement?
1) Neer- positive with 70-110 degrees of forward flexion
2) Hawkins- internal rotation with passive forward flexion to 90 degrees
3) Internal impingement- pain with abduction and external rotation
What are common radiographic findings in shoulder impingement?
1) proximal migration of the humerus (rotator cuff arthropathy)
2) traction osteophytes
3) coracoacromial ligament ossification
4) type III-hooked acromion
Which patients have poorer outcomes with subacromial decompression?
worker’s compensation
What are the 5 main phases of throwing?
1) wind-up
2) cocking (early and late)
3) acceleration
4) deceleration (highest torque phase)
5) follow-through
What are shoulder exam findings of rotator cuff tear?
1) Internal rotation lag- hand held away from lumbar spine, will fall into spine if tear of subscap; can also do belly press
2) Jobe’s test and drop arm-supraspinatus
3) Hornblower’s- arm held in external rotation, positive for teres minor tear if drops into internal rotation
What are shoulder exam findings of SLAP tear?
1) Crank test- abduct arm and apply axial pressure with IR/ER, pain or crepitus is positive
2) O’Brien’s test- adduct arm 10° and forward flex 70°, apply pressure with hand supinated and pronated; positive if pain with pronation but not supination (if pain is “deep” then SLAP, if superficial then AC joint pathology)
What are shoulder exam findings of biceps injuries?
1) Speed’s test- forward elevate the arm against resistance with elbow extended
2) Yergason’s- resisted supination of pronated wrist with elbow flexed
3) Popeye sign- indicates long head rupture
What are shoulder exam findings of shoulder instability?
1) Apprehension and relocation- ER and abduct to 90°, will be apprehensive will dislocate, posterior direct force at GH joint will relieve pain and apprehension (anterior instability)
2) Anterior drawer (anterior instability); 1-to glenoid rim, 2- over glenoid rim but reduces, 3- locks outside glenoid rim
What are shoulder exam findings of AC joint pathology?
1) O’Brien’s test- adduct arm 10° and forward flex 70°, apply pressure with hand supinated and pronated; positive if pain with pronation but not supination (if pain is “deep” then SLAP, if superficial then AC joint pathology)
2) Adduction test- pain in AC joint with cross body adduction
3) Sulcus sign- pull arm inferior; sulcus is sign of MDI (multidirectional instability)
4) Loss of internal rotation can be sign of posterior dislocation
What are shoulder exam findings of other pathology?
1) Wright’ test- (for thoracic outlet syndrome) passively externally rotate and abduct the patient’s arm while having the patient turn their neck away from (Adson’s turns head towards) the tested extremity; positive if loss of pulse
2) Medial scapular winging- inferior border of the scapula migrates medially; injury to long thoracic nerve
3) Lateral scapular winging- inferior border of scapula migrate laterally; injury to CN XI (spinal accessory n.)
What is the most common tendon affected by calcific tendonitis?
Supraspinatus tendon; MC in women aged 30-60; a/w DM and hypothyroidism; pain MC in resorptive phase
When compared to tenotomy of biceps tendon, what are some advantages of a biceps tenodesis?
tenodesis may decrease subjective arm cramping and improve cosmesis
Distal clavicle osteolysis is commonly seen in what patients?
Weight lifters; repetitive microfractures lead to osteopenia; treat with activity modification, NSAIDs, steroid inj or arthroscopic DCE
Which type of shoulder dislocation has the highest incidence of neurovascular injury?
Inferior; Luxatio erecta
What is little leaguer’s shoulder?
A salter harris I injury to the proximal humerus physis (hypertrophic zone) seen in adolescent pitchers (breaking pitches)
Can lead to premature growth arrest
What are a reverse Bankhart lesion and a Kim lesion?
Reverse bankhart- tear of posterior labrum
Kim lesion- incomplete avulsion of posterior labrum
What structure is at risk when repairing a posterior labral tear?
The axillary n.
Travels within 1mm of the inferior shoulder capsule and glenoid rim
What is scapulothoracic dyskinesis?
Abnormal scapula motion leading to shoulder impingement and dysfunction cause are multifactorial:
1) neurologic injury
2) pathologic thoracic spine kyphosis
3) periscapular muscle fatigue
4) poor throwing mechanics
5) secondary to pain (shoulder, neck)
Treat with PT, core strengthening and teaching proper throwing mechanics
What are the provacative tests for thoracic outlet syndrome?
Wright
abduction and external rotation with the neck rotated away leads to loss of pulse and reproduction of symptoms
Adson
extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling
Roos
hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms
What are risk factors for a triceps rupture?
1) Renal osteodystrophy
2) Anabolic steroid use
3) Fluoroquiniolones
4) Local steroid injection
What is the MC mechanism of a triceps rupture?
Eccentric contraction
Common in males and weight lifters, may see a “flake sign” on lateral radiograph
What nerve compression syndrome, that if becomes chronic can lead to deltoid and teres minor atrophy?
Quadrilateral space syndrome;
compression of the axillary n. and posterior circumflex humeral a. in quadilateral (quadrangular) space
What are the boundaries of the quadrangular space?
Lateral- surgical neck of humerus
Superior- Subscap and teres minor
Inferior- teres major
Medial- long head of triceps
What are the symptoms of quadrangular space syndrome?
Poorly localized pain in the posterolateral shoulder that is usually worse at night and with overhead activities; point tenderness over quadrangular space
MRI will show teres minor and deltoid atrophy; EMG is diagnostic and shows axillary n. involvement
What are indications for shoulder hemiarthoplasty?
Contraindications?
Indications:
1) DJD with rotator cuff arthropathy and shoulder flexion of >90°
2) DJD and risk of glenoid loosening (young active, laborer)
3) Osteonecrosis of humeral head
4) 3-4 part fractures in older
5) head splitting fractures
Contraindications:
1) infection
2) neuropathic joint
3) unmotivated patient
4) Coracoacromial ligament deficiency (prevents anteriosuperior migration if have RCT)
What is the most important determinant of outcome in shoulder hemiarthroplasty?
Condition of the rotator cuff
Outcomes also inversely proportional to age and time from injury to operation
What are important techniques when implanting a shoulder hemiarthroplasty?
1) aim for 30° retroversion
2) Cemented is better
3) tuberosity reduction should be anatomic (MC cause of failure)
4) Greater tuberosity shoulder be 3-5mm below humeral head
5) Distance from top of prosthesis to superior border of pec major is 56mm
What is the MC mechanism for pectoralis major rupture?
excessive tension on a maximally eccentrically contracted muscle
Almost always male; common in weight lifters
What are the physical exam findings for pectoralis major rupture?
1) Ecchymosis down arm (tendon avulsion)
2) Weakness or pain with resisted adduction and internal rotation
3) Pt may describe a tearing sensation
4) Palpable defect in axillary fold, asymmetry of chest
Most are treated with NSAIDs, rest and ice; athletes can have primary repair
Where is the MC location for an OCD lesion of the elbow?
Capitellum
Gymnast or throwing athletes; typically after age 10 with lateral arm pain and possible elbow effusion. Also clicking or catching in joint
What is the position of the shoulder for a glenohumeral fusion?
30-30-30
Abduction-flexion-internal rotation
What are a few indications for a shoulder fusion?
Brachial plexopathy
Salvage for failed TSA
Paralytic disorders
What is an overuse syndrome of the flexor-pronator mass?
Medial epicondylitis (Golfer's elbow) Pronator teres and FCR most commonly
What is the treatment for medial epicondylitis of the elbow?
RICE and NSAIDs for up to 6 months; then consider debridement of flexor-pronator mass
Where is the spiral groove of the humerus (contains radial n.) in relation to the articular surface of the trochlea?
13cm proximal
Where do the brachialis and biceps brachii attach on the forearm?
Brachialis- 11mm distal to tip of coracoid on the ulna
Biceps- radial tuberosity
How much valgus stability does the radial head provide?
~30%; most important in 0-30°
Where does the radial n. pierce the lateral intermuscular septum?
7.5cm proximal to the trochlea; lies btw the brachialis and brachioradialis
What is the normal valgus carrying angle for the elbow?
Males- 7°
Females- 13°
What is the primary stabilizer of varus stress of the elbow?
LUCL; originates at the lateral humeral epicondyle and inserts on the tubercle of the supinator crest
Incompetence of what structure can result in a positive lateral pivot shift test of the elbow?
LUCL
What is the management of an elbow with PLRI (posterolateral rotatory instability)?
Reduction and splinting in 90°; early AROM if stable; if unstable LUCL reconstruction
Where and what is the lesion associated with lateral epicondylitis?
Tendinosis and inflammation at the origin of ECRB; on histo shows angiofibroplastic hyperplasia
What provocative tests will exacerbate lateral epicondylitis?
1) Resisted extension of the wrist with elbow extended
2) Maximal wrist flexion
3) Resisted extension of the long fingers
What is the treatment for lateral epicondylitis?
95% success for non-op treatment 1) tennis modifications 2) Counter force strap 3) injections (up to three) 4) Stretching If non-op fails after 9-12 months, open release
What is little leaguers elbow?
Spectrum of injuries to the medial side of the elbow including:
1) medial epicondyle stress fracture (medial apophysitis)
2) UCL sprain
3) plexor-pronator mass strains
due to repetitive valgus stress overload during pitching (curveballs)
In pitchers elbow where are the stress forces?
Posteromedial humerus and olecranon, lateral radio-capitellar compression
In the surgical treatment of pitcher’s elbow, what can lead to valgus instability?
Over-resection of the posteromedial olecranon which increases stress on the MCL
What is the treatment for an olecranon stress fracture that fails conservative tx?
Compression screw
What is the most common cause of elbow arthritis?
1) Rheumatoid; most common; affects elbow in 20-50% of RA patients
2) Post-traumatic; 2nd-most common;
3) Primary OA (~2%)
What are the treatment options for elbow arthritis?
1) NSAIDs, injections, rest and ice
2) Arthroscopic debridement and capsular release
3) Interposition arthroplasty
4) TEA
5) Arthrodesis
Which portal is typically not used during elbow arthroscopy?
postero-medial
Where does the earliest loss of cartilage occur in knee with OA?
the 30-60 degree flexion zone
What are some specific radiographic signs of pathology of the knee?
Segond sign: Small lateral tibial avulsion fracture that indicates a ACL tear
Patella alta: Patellofemoral pathology
Pellegrini-Stieda Sign: Medial femoral condyle avulsion fx (Chronic MCL injury)
Patella baja: Arthrofibrosis
Fairbanks changes: DJD - post meniscectomy (square condyle, peak eminences, ridging, narrowing)
Lateral MFC lesion: OCD
Square lateral condyle: Discoid meniscus
3 sagittal MRI images: Discoid meniscus
Bipartate patella: Must differentiate from fracture
What treatment is indicated in patellofemoral syndrome?
Rest, NSAIDs, PT (VMO strengthening, core exercises)
What is the most common location for spontaneous osteonecrosis of the knee (SONK)?
Epiphysis of medial femoral condyle
most common in middle age and elderly, affects females (>55yo) more frequently than males, 99% only have one joint involved
What pathologies must be differentiated from SONK?
1) osteochondritis dissecans; more common on lateral aspect of medial femoral condyle in adolescent males
2) transient osteoporosis; more common in young to middle age men
3) bone bruises and occult fractures; associated trauma, bone fragility or overuse
4) idiopathic osteonecrosis of the knee; lesion is not crescent shaped
What is the treatment of choice for SONK when conservative measures fail?
UKA or TKA; usually affects older females and lesions are large
Conservative measures are NSAIDs, protected weight bearing
What is the epidemiology of Osgood Schlatter’s?
Is a osteochondrosis or traction apophysitis of tibial tubercle
1) More common in boys
2) female 8-12yo, males 12-15yo
3) Jumpers, or sprinters
4) bilateral 20-30%
5) resolves when fully grown
What is a disease that is similar to Osgood Schlatter’s but affects the inferior pole of the patella?
Sinding-Larsen-Johansson syndrome
Common in CP pts
What is the treatment for Osgood Schlatter’s?
NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease tension on the apophysitis and quadriceps stretching
If symptoms severe then can cast
What are the most common locations of apophyseal fractures?
1) ASIS (origin of sartorius)
2) ischium (origin of hamstrings)
3) lesser trochanter (iliopsoas)
4) AIIS (rectus femoris)
5) iliac crest (abdominal muscles)
What are the 3 types of snapping hip?
1) External coxa saltans (d/t IT band over greater troch)
2) Internal coxa saltans (d/t iliopsoas over femoral head)
3) Intra-articular (d/t synovial chondromatosis, loose bodies or labral tear)
“external snapping one can see from across the room, while internal one may hear from across the room”)
How is external snapping hip diagnosed and treated?
1) Positive Ober’s test: IT tightness (limited adduction) with hip extension
2) NSAIDs, activity mod, PT, injections
3) Bursal debridement with Z-lengthening of IT band
How is internal snapping hip diagnosed and treated?
1) Pain when ER/flexed hip brought to IR/extended; US; bursography
2) NSAIDs, activity mod, PT, injections
3) Open or arthroscopic release of iliopsoas
What is the most common anatomical pattern of the sciatic nerve as it exits the pelvis?
As a single nerve anterior to the piriformis muscle.
Popliteal artery entrapment has what identifying clinical sign?
Calf cramping with light exercise that improves with vigorous exercise
What is the “female athlete triad” and what can be a/w these patients?
1) amenorrhea
2) eating disorder
3) osteoporosis
Stress fractures
What is the treatment for femoral neck stress fractures?
Tension side (superior neck)- ORIF with screws Compression side (inferior neck)- NWB; if >50% of neck consider ORIF
Where do rectus femoris strains most commonly occur?
Distally
Proximal injuries may present with AIIS avulsions
What is the etiology of chronic exertional compartment syndrome?
The muscles cannot clear metabolic waste products quickly enough; 40% of individuals will have a fascial hernia anteriorly
What are the diagnostic criteria for chronic exertional compartment syndrome?
1) resting (pre-exercise) pressure > 15 mmHg
2) immediate (1 minute) post-exercise is > 30 mmHg
3) 5 min post exercise is >20 mmHg
Patients have pain with ~10min of exercise that lasts 20-30 min after cessation of exercise
What is the mechanism and treatment for a groin (adductor) strain?
External rotation of an abducted leg
Rest, ice, PT with stretching and progressive strengthening (avoid immobilization)
What is the most common location of a hamstring injury?
Myotendinous junction; seen in sprinters
Avulsions from ischial tuberosities is less common; seen in skiers
What is the primary cell involved with muscle healing?
Satellite cells
What is the treatment for hamstring injuries?
1) Protected WB for 4 weeks then stretching and strengthening; return to play when 90% strength
2) Can surgically repair proximal avulsion fxs
What activities are a/w stress fractures of the ribs?
Basketball, rowing, golfing, pitching, weight lifting and ballet
How are tibial stress fractures treated?
1) Activity modification, protected weight bearing
2) IM nail if “black line” present
In a football player that has arm numbness and weakness what would prompt and MRI?
Bilateral symptoms
In a football player that suffers a stinger what criteria should be met prior to return to play?
No pain, normal sensation, demonstration of full range of motion, and 5/5 strength of the right upper extremity musculature
Define: Heat Cramps Heat Syncope Heat Exhaustion Heat Stroke
Heat Cramps- muscle cramps d/t electrolyte imbalance
Heat Syncope- loss of consciousness; normal body temp
Heat Exhaustion- N/V, normal CNS, core temp less than 39C
Heat Stroke- CNS abnormal, anhidrosis, core temp >40.5C
What condition is characterized by hyperthermia, central nervous system dysfunction, and loss of thermo-regulatory function?
Heat stroke; treat with rapid cooling in ice bath, cold IV fluids
What are infections that commonly affect athletes?
1) MRSA (turf burns increase risk, mupirocin or I&D)
2) Tinea (tx w/ antifungals, no sports for 48hrs)
3) Herpes gladitorium (acyclovir, no sports until all lesions crusty and no new lesions for 5 days)
4) Acne mechanica (folliculitis)
5) Impetigo (erythromicin and bactroban)
6) mononucleosis (splenomegaly, no contact sports for 3-5 weeks, splenic rupture MC at 3 weeks)
What is the most common cause of death in the young athlete?
Sudden cardiac death
What is the best screening tool to identify cardiac abnormalities in high school athletes?
H&P
Hypertrophic cardiomyopathy presents with what type of murmur?
II/VI that increases with standing or valsalva maneuver
What is commotio cordis and how is it treated?
Ventricular fibrillation caused by sudden blunt force trauma to the chest; tx with immediate cardiac defibrillation
What are the parts of the female athlete triad?
1) Amenorrhea
2) Osteoporosis
3) Eating disorder
How is the female with athletic triad treated?
1) Eating behavior counseling
2) Calcium and vit D supplementation
3) Reduced training intensity
4) OCPs
