MSK Shoulder Flashcards
Normal shoulder ROM
Flexion: Extension: Abduction Adduction IR ER
Flexion: 180 Extension: 60 Abduction 180 (120 with thumb pointed down) Adduction: 60 IR: 90 ER: 90
Name the muscles responsible for shoulder flexion 4
- anterior deltoid (axillary nerve from posterior cord C5/6)
- Pec major, clavicular portion (medial and lateral pectoral nerves C5-T1)
- Biceps brachii (musculocutaneous nerve from lateral cord C5/6)
- Coracobrachiolis (musculocutaneous nerve from lateral cord C5/6)
Name the muscles responsible for shoulder extension 5
- posterior deltoid (axillary nerve from posterior cord C5/6)
- Lats dorsi (thoracodorsal nerve from posterior cord C6/7/8)
- Teres Major (lower subscapular nerve from posterior cord C5/6)
- Triceps long head (`radial nerve from posterior cord C6/7/8)
- Pec major (sternocostal portion - medial and lateral pectoral nerves C5-T1)
Name the muscles responsible for shoulder abduction 2
- middle deltoid (axillary nerve from posterior cord C5/6)
2. Supraspinatus (suprascapular nerve from upper trunk C5/6)
Name the muscles responsible for shoulder adduction 7
- pectoralis major (medial and lateral pectoral nerves C5-T1)
- Lat dorsi (thoracodorsal nerve from posterior cord C6/7/8)
- Teres Major (lower subscap n from lateral cordC5/6/7)
- Coracobrachialis (musculocutaneous n from lateral cord C5/6/7)
- Infraspinatus (suprascapular nerve from upper trunk: C5/6)
- Long head of triceps (radial n from posterior cord C6/7/8)
- Anterior and posterior deltoid (axillary nerve from posterior cord C5/6)
Name the muscles responsible for shoulder internal rotation: 5
- Subscapularis (upper and lower subscap nerves from PC C5/6)
- Pectoralis major (medial and lateral pectoral n C5-T1)
- Lats (thoracodorsal n from PC C5/6)
- Anterior deltoid (axillary from PC C5/6)
- Teres major (lower subscap from PC C5/6)
Name the muscles responisble for shoulder external rotation 4
- infraspinatus (suprascapular nerve from upper trunk C5/6)
- Teres Minor (axillary nerve from PC C5/6)
- Deltoid, posterior portion (axillary from PC C5/6)
- Supraspinatus (suprascapular nerve from upper trunk C5/6)
Name the 6 components of the glenohumeral joint
- glenoid fossa
- labrum
- glenohumeral capsule
- glenohumeral ligaments
- dynamic shoulder stabilizers
- Static shoulder stabilizers
describe the balance between the glenohumeral and scapulothoracic joint during arm abduction
There are 2 degrees of glenohumeral motion for every 1 degree of scapulothoracic motion during arm abduction (120 glenohumeral and 60 scapulothoracic motion)
Scapulothoracic motion allows the glenoid to _____ and permits glenohumeral ____ without acromial impingment
rotate, abduction
____ is the lateral aspect of the scapula that articulates with the humerus. What percentage of the humeral head articulates here?
glenoid fossa - 30%
_____ is the fibrocartilaginous tissue surrounding the glenoid fossa
functions? 3
Labrum
- serves as attachment for glenohumeral ligaments and tendons as well as the shoulder capsulel
- prevents anterior and posterior humeral head dislocation
- deepens the glenoid fossa and increases overall contact of the humeral head with the glenoid by 70% `
The glenohumeral capsule arises from ____ and covers the entire head of the humerus and attaches _____
labrum, neck of humerus
The glenohumeral capsule thickens anteriorly to form ____
glenohumeral ligaments
Name the 3 glenohumeral ligaments:
- Superior glenohumeral ligament
- Middle glenohumeral ligament
- Inferior glenohumeral ligament
Which GH ligament is the primary anterior stabilizer above 90 degrees?
inferior glenohumeral ligament
Which GH ligament limits anterior shoulder translation?
Middle glenohumeral ligament
Which GH ligament prevents shoulder translation in the inferior directioN?
Superior GH ligament
Which GH ligaments provide stability from 0-90 degrees of abduction?
Superior and middle glenohumeral ligaments
Name the dynamic stabilizers of the shoulder 6
- rotator cuff - Supraspinatus, Infraspinatus, Teres minor, Subscapularis
- Long head of biceps tendon
- Deltoid
- Teres major
- Latissiumus dorsi
6 Scapular stabilizers (traps, serratus anterior) play a supporting role in stabilizing the GH joint during ROM.
Name the static stabilizers of the shoulder joint 4
- Glenoid
- Labrum
- Shoulder capsule
- Glenohumeral ligaments (3)
The _____ ligament connects the distal end of the clavicle to the acromion, providing horizontal stability
acromioclavicular ligament
The ____ ligament connects the coracoid process to the clavicle and anchors the clavicle to the coracoid process, preventing vertical translation of the clavicle.
It is made up of what two parts?
Coracoclavicular ligament
Conoid (medial) & Trapezoid (lateral)
The ____ ligament attaches the coracoid process to the acromion
coraco-acromial ligament
two most common mechanisms of injury to AC ligaments:
- direct impact to the shoulder
2. falling on an outstretched arm
Describe the classification of AC joint separations
AC CC Clavicle
Type I partial sprain intact no displacement
Type II complete tear partial sprain no disp
Type III Complete Complete tear superior
Type IV Complete Complete Post and sup into trap, giving buttonhole appearance
Type V Complete Complete (more severe than III with CC space increased over 100%) Indicates disruption of deltoid and trapezius fibers Superior and posterior clavicle
Type VI Complete Complete inferior
In AC separation, if gross deformity is noted, it is at Type _____ or greater
III
what is the provocative test for AC joint impingement?
cross-chest (horizontal adduction or scarf) test: passive adduction of teh arm across the midline causing joint tenderness.
On Xray, AC joints separations:
1 Weighted how much?
2 Type III injuries may show ____% widening of the clavicularcoracoid area
3. Type V injuries may show ____% widening
- 10lb
- 25-100%
- > 100%
Treatment of AC joint injuries:
I - VI
I and II: RICE; NSAIDs; sling for comfort; return to play when asymptomatic with full ROM (I: 2 weeks, II: 6 weeks)
III: controversial; surgically treat heavy laborers or athletes.
IV-VI: surgery - ORIF or distal clavicular resection with recon of CC ligament
Chronic - CSI injection or surgery as above
What are the complications of AC joint injuries?
- associated fractures and dislocations
- distal clavicle osteolysis; degeneration of the distal clavicle with assoiciated osteopenia and cystic changes
- AC joint arthritis - may get relief from lidocaine injection
Name the 3 classifications of Glenohumeral joint instability
- instability - translation of the humeral head on glenoid fossa. may result in subluxation or dislocation
- Subluxation - incomplete separation of humeral head from the fossa with immediate reduction
- Dislocation - complete separation of the humeral head from the glenoid fossa without immediate reduction.
- With regard to glenohumeral instability, which is the most common direction?
- What age of the population?
- Mechanism?
- Complications?
- Anterior/inferior
- younger population with high recurrence rate
- Arm abduction and external rotation
- axillary nerve injury
Patient presents with an adducted and internally rotated arm. Etiology?
Posterior glenohumeral instability
likely result of seizure.
Mechanism of posterior glenohumeral instability?
landing on a forward flexed adducted arm, seizure
Discuss the two patterns of glenohumeral instability
Traumatic: T.U.B.S.
- T: Traumatic Shoulder Instability
- U: Unidirectional
- B: Bankart lesion
- S: Surgical management
Atraumatic. A.M.B.R.I.
- A: Atraumatic shoulder instability
- M: Multidirection instability
- B: Bilateral lesions
- R: Rehabilitation Management
- I: Inferior capsular shift, if surgery
Anterior dislocations of the glenohumeral joint can cause what two lesions?
- Bankart lesion - tear of the glenoid labrum off the anterior glenoid allowing the humeral head to slip anteriorly
- Hill-Sachs lesion - compression fracture of the posterolateral humeral head caused by abutment against the anterior rim of the glenoid fossa
In Bankart lesions,
- most commonly associated with _____ instability
- May be associated with ____
- anterior instability
2. avulsion fracture of the glenoid rim
_____ is a compression fracture of the posterolateral humeral head caused by abutment against the anterior rim of the glenoid fossa
hill-sachs lesion
With regard to hill-sachs lesions
- most common with ____ dislocations
- A lesions > _____% of the articular surface may cause instability
- A notch occurs on the posterior lateral aspect of the humeral head due to _____
- anterior
- 30%
- recurrent impingement
Posterior glenohumeral dislocations cause what lesions?
reverse bankhart and reverse hill sachs.
What pathology?
symptoms include early shoulder fatigue, pain, numbness, and parasthesia. Shoulder might slip in and out of place most commonly when the arm is placed in abduction and external rotation (“throwing position”)
Dead arm syndrome - seen in pitchers and volleyball players who require repetitive overhead arm motion.
What is the test for dead arm syndrome?
laxity exam: patient’s say they are “double jointed” which is lay term for capsular laxity.
- ask patient to touch the thumb against the volar (flexor) surface of the forearm.
- patients with lax tissues are more likely than others ot be able to voluntarily dislocate the shoulder.
Name the provocative tests for ANTERIOR glenohumeral instability (4)
- Apprehension test - feeling of anterior shoulder instability with 90 degrees shoulder abduction and external rotation, causing apprehension (fear of dislocation in the patient)
- Relocation test: supine apprehension test with a posterior directed force applied to the anterior aspect of the shoulder not allowing anterior dislocation. This force relieves the feeling of apprehension
- Anterior drawer test - passive anterior displacement of the humeral head on the glenoid
- Anterior load and shift test - essentially a modified form of the anterior drawer test; humeral head is loaded against the glenoid and then passively displaced anteriorly. positive if there is reproduction of the patient’s symptoms of instability, pain, and crepitation.
What are the three tests for posterior glenohumeral joint instability?
- Jerk test - place the arm in 90 degrees of flexion and maximum internal rotation with the elbow flexed to 90 degrees. Adduct the arm across the body in the horizontal plane while pushing the humerus in a posterior direction. The patient will jerk away when the arm nears midline to prevent posterior subluxation or dislocation of the humeral head.
- Posterior drawer test
- Posterior load and shift test.
What is the test for multidirectional glenohumeral instability?
sulcus sign: the examiner pulls down on the patient’s arm with one hand as he stabilizes the scapula with the other. If an indentation develops between the acromion and the humeral head, the test is positive. This suggests increased laxity in the GH joint.
which exercises are warranted in a anterior GH instability injury?
PROM to stabilize and strengthen the shoulder girdle complex plus codman pendulum exercises
muscle strengthening alone rarely prevents recurrent dislocations.
after ____ anterior dislocations, a patient has 100% chance of recurrence
3; surgery should then be considered.
Rehab is generally adequate for which type of glenohumeral instability? strengthening whatmuscle group is imperative?
posterior - immobilize in neutral position for roughly 3 weeks.
posterior shoulder-scapula musculature is imperative (infraspinatus, posterior delt, teres minor, trapezius, serratous anterior) - phase may last up to 6 months.
In the event of a failed rehab program, ____ is the surgical procedure of choice for recurrent posterior shoulder dislocations of traumatic origin.
a posterior capsulorrhaphy
What is a SLAP lesion?
Superior glenoid Labral tear in the Anterior to Posterior position.
labrum tears usually occur secondary to _____
repetitive overhead movement or sports (baseball, volleyball) or trauma
what is the provocative test to check for glenoid labrum tears?
load and shift test - the examiner grasps the humeral head and pushes it into the glenoid while applying an anterior and posterior force. A positive test indicates the labrum instability and is displayed by excess translation.
What is the most common cause of shoulder pain?
impingement syndrome
_____ is a narrowing of the subacromial space causing compression and inflammation of the subacromial bursa, biceps tendon, and rotator cuff (most often involving the supraspinatus tendon.
impingement
Impingement of the supraspinatus tendon occurs under the _____ and the ____ and occurs with arm ___ and ____
acromion and the greater tuberosity; arm abduction and internal rotation
What are the stages for subacromial impingement syndrome
Neer
Stage I: edema or hemorrhage - reversible (age 40)
Name the muscles of the rotator cuff
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Rotator cuff tears occur primarily in the _____ which is weakend as a result of many factors including injury, poor blood supply to the tendon, and subacromial impingement.
supraspinatus tendon
The anatomic shape of the patient’s acromion has been linked wiht occurrence rates of rotator cuff tears. Patients with ___ and ____ acromions have a higher risk of rotator cuff tears.
curved or hooked
Name the three types of acromion morphology
Type 1 - flat
Type 2 - curved
Type 3 - hooked
___ and _____ are commonly affected tendons in rotator cuff tears
supraspinatus and biceps tendon - due to location under the acromion.
weakness in ____, ____, and ____ suggest supraspinatus or biceps pathology
abduction, flexion, and internal rotation (Hawkin’s sign)
inability to initate abductio may indicate a tear.
What is the neer’s impingement sign?
stabilize the scapula and passively forward flex the arm greater than 90 degrees eliciting pain. Pain indicates the supraspinatus tendon is compressing between the acromion and greater tuberosity.
what is the Hawkins impingement sign?
Positive test?
Stabilize the scapula and passively forward flex (up to 90 degrees) the internally rotated arm eliciting pain.
Positive test indicatesthe supraspinatus tendon is compressing against the coracoacromial ligament
What is the painful arc sign?
abducting the arm with pain occuring roughly between 60-120 degrees
What is the supraspinatus test?
pain and weakness with arm flexion abduction and Internal rotation (thumb pointed down)
With abduction the humerus with laterally externally rotate. In assessing the integrity of the supraspinatus, the patient should internally rotate the humerus forcing the greater tuberosity under the acromion. In this position the max amount of abduction is to 120 degrees
What is the drop arm test
the arm is passively abducted to 90 degrees and internally rotated. The patient is unable to maintain the arm in abduction with or without a force applied.
(initially the deltoid will assist in abduction but fails quickly)
this indicates a complete tear of the cuff.
With impingement, and on Xray, the greater tuberosity may appear _____.
In chronic rotator cuff tears, the proximal humerus may appear _____ or ______.
cystic
superior migrated or flattened
may also have subacromial sclerosis.
Name the movements of the scapula
Elevation Depression Protraction (abduction) Retraction (adduction) Upward (lateral) rotation Downward (medial) rotation Anterior Tipping Posterior Tipping
Medial scapular winging is a result of ___- weakness. Often a result of ____ nerve injury.
serratus anterior weakness
long thoracic nerve palsy
bench pressing very heavy weights or wearing heavy packstraps can also impinge the nerve.
Lateral scapular winging results from ____ muscle weakness. can but due to ____ nerve lesion.
trapezius muscle; spinal accessory nerve lesion
nerve injury occurs in the posterior triangle of the neck.
______ XR view assesses acromion morphology
supraspinatus outlet view (15 degrees caudal tilt for a transcapular Y view)
Describe three stages of treatment for impingement, chronic partial and full tears
- Acute phase (up to 4 weeks)
- relative rest, reduce pain and inflammation. reestablish nonpainful and scapulohumeral range of motion - Recovery phase (months)
- improve ROM and proprioception. full pain free ROM. Improve cuff and scap stabilizers. Assess single planes of motion in activity-related exercises. - Functional phase - continue strengthening, increasing power, and endurance. CSI injuction (up to 3 yearly - may weaken collagen tissue leading to more microtrauma.
What are the surgical indications for impingement, chronic partial or full tears
- full thickness or partial tears that fail conservative treatment.
- reduction or elimination of impingement pain - make sure patient realizes chronic issues will likely not regain function
Describe the procedure for the following
- partial tears (40% thickness)
- Acute rotator cuff tears (athletes/trauma)
- partial anterior acromioplasty and coracoacromial ligament lysis (CAL)
- excise and repair
- surgical repair within first 3 weeks results in significantly better overall function than later reconstruction.
Regarding DJD, Pain is most common in ___ of the shoulder.
More common in day or night?
Internal rotation of the shoulder but may also be seen with abduction
Pain may be nocturnal and relieved by rest.
Changes seen on XR with DJD of shoulder? 6
- irregular joint surfaces
- joint space narrowing (cartilage destruction)
- subacromial sclerosis
- osteophyte changes
- flattened glenoid
- cystic changes in humeral head
surgery for DJD of shoulder?
What indications? 3
total shoulder arthroplasty (TSA)
- pain
- AVN
- neoplasm
Precautions s/p TSA:
Stage 1: 0-6 weeks
Stage 2: 6-12 weeks
Stage 3: greater than 12 weeks
- Stage 1 0-6 weeks
- avoid active abductions
- extension >0.
- Sling immobilization
- no ER >15 degrees
- No active ROM, NWB.
- Gentle PROM (Cogman’s),
- gentle AROM (wall-walking)
- isometric exercising (progressing) - Stage 2: 6-12 weeks
- d/c sling
- start light weights
- isotonics, AAROM, AROM - Stage 3: >12 weeks
- previous ROM precautions cancelled
- start proressive resistive exercises, active ranging, stretching
2.
____ is the surgical resection and fusion of the glenohumeral joint. Typical patient?
ARthrodesis of shoulder - young heavy laborer with repetitive trauma to the shoulder.
three indications for shoulder arthrodesis
- severe pain in shoulder secondary to OA
- Mechanical loosening of the shoulder arthroplasty
- Joint infection
What are the fusion positions for shoulder arthrodesis?
- 50 degrees abduction
- 30 degrees forward flexion
- 50 degrees internal rotation
Where does biceps tendonitis usually occur?
long head of biceps tendon at bicipital groove of the humeral head.
Mechanism of impingement for biceps tendonitis
between the head of the humerus, acromion, and coracoclavicular ligaments with elevation and internal rotation of the arm.
Most common site of biceps rupture
proximal end of the long head of the biceps tendon. distal is rare.
what pathology?
Sharp pain, audible snap, ecchymosis, and visible bulge in the lower arm with tendon rupture
biceps rupture.
Name the two tests for biceps tendonitis.
Biceps rupture? (one test)
- Yergason’s test - determines stability of the long head of the biceps tendon in the bicipital groove. Pain at anterior shoulder with flexion of the elbow to 90 degrees and supination of the wrist against resistsance
Speeds test - pain at the anterior shoulder with flexion of the shoulder, elbow extended, and supinated against resistance.
- Biceps rupture - Ludington’s test - an obvious deformity seen with flexion of the biceps muscle.
two reasons to repair biceps tendon rupture
- younger individuals who require heavy lifting may need reattachment (biceps tenodesis)
- cosmetic reasons.
With regard to calcific tendonitits, most commonly affects _____.
Pain when?
supraspinatus tendon. Size of deposit has no correlation to the symptoms.
Pain with ROM, particularly abduction and overhead activities
Adhesive capsulitis is more common in _______
May be 3 etiologies?
women >40 yoa
autoimmune, trauma, inflammatory
Name 8 conditions associated with adhesive capsulitis
- intracranial lesions - CVA, hemorrhage, brain tumor
- clinical depression
- shoulder hand syndrome
- Parkinson’s disease
- iatrogenic disorders (prolonged immobilization)
- Cervical disc disease
- IDDM
- Hypothyroidism`
In adhesive capsulitis, which ROM is lost first?
External rotation and abduction
shoulder flexion, adduction, and extension are subsequently lost
Name the stages of adhesive capsulitis
- Pain with ROM, no restricted ROM (1-3 months)
- Freezing stage (3-9 months) - pain with ROM, progressive loss of ROM
- Frozen stage( 9-15 months) - decreased pain, restricted ROM
- Thawing stage (15-24 months) - progressive restoration of ROM
What might be seen on arthrogram of adhesive capsulitis?
decreased volume of the joint, which can be realized by the small amount of contrast (less than 5ml) that can be injected.
surgical treatment of adhesive capsulitis is indicated when? 2
- manipulation under anesthesia may be indicated if there is no substantial progress after 12 weeks of conservative treatment
- arthroscopic lysis of adhesions - usually reserved for patients with IDDM who do not respond to manipulation.
___ is winging of the medial border of the scapula away from the ribs
medial winging - more evident when patient forward flexes the arms or does a wall pushup
______ is when there is rotary winging of the scapula around the thorax.
lateral winging- upper traps can be tested by resisted shrug.
- middle and lower traps can be tested by prone rowing exercise
scapular fractures are typically associated with what other injuries? 3
- rib fractures
- pulmonary contustions
- PTX/hemothorax
Name the 7 possible fracture sites of the scapula
- glenoid
- glenoid rim
- coracoid,
4 &5 scapular neck and body, - acromion
- Spine
typical treatment for scapular fracture?
- arm sling followed by early ROM within 1-2 weeks after injury.
2 ORIF for large displaced fractures.
Patients with isolated scapular body fractures should be considered for hospital admission due to the risk of pulmonary contusion.
Classification of clavicle fractures
Medial
middle (most common 80%)
Distal
Progressive ROM may be reinstituted at what point after clavicle fracture
after 3 weeks of immobilization
3 indications for surgery in clavicle fractures
- open clavicle fractures
- grossly displaced fracture with skin tenting
- fracture with significant medialization of the shoulder girdle
Displaced lateral clavicle fractures > ______ at the AC joint are best treated surically
> 1cm
describe the 4-part classifcation of humeral fractures
one of these parts must be angulated _____ degrees or displaced at least ____ to be considered displaced
areas include:
- greater tuberosity
- lesser tuberosity
- humeral head
- humeral shaft
45 degrees
1 cm
One part: nondisplaced, impacted fractures, all parts are still in alignment
Two parts - one fragment is displaced with respect to the other three
Three part - two fragments are displaced
Four part - all fragments are displaced
Common location for humeral fractures: 4
Surgical neck (most common)
Greater tuberosity
Lesser tuberosity
anatomical neck
In fracture at surgical neck of humerus ____ ist he principle abductor which causes what deformity?
supraspinatus - abduction of the proximal fragment of the humerus
Complications of humeral fractures:
- brachial plexus injuries:
- ____ nerve most common in surgical neck fractures
- ____ and _____ nerves also possible
- ____ nerve is least affected - ____ artery compromise may be evident
- Avascular necrosis of the humeral head may occur with anatomic neck fractures secondary to interruption of _____
- brachial plexus injuries:
- axillary nerve most common in surgical neck fractures
- radial and ulnar nerves also possible
- median nerve is least affected - axillary arter compromise may be evident
- Avascular necrosis of the humeral head may occur with anatomic neck fractures secondary to interruption fo teh humeral circumflex vasculature.
Neers classification of rotator cuff pathology:
Stage I (less than 25 yoa) inflammation and edema Stage II (25-40yoa) fibrosis and tendonitis Stage III (>40 yoa) partial or complete tear.
Can get primary vs secondary impingement
Name the 7 stabilizers of the scapula
- serratus anterior
- trapezius
- pec minor
- rhomboid minor
- rhomboid major
6 lats - levator scap
name the directions of the scapula and the muscles most responsible for each
- Elevation - levator scap, upper trap
- depression - lower trap
- retraction/adduction - major and minor rhomboid, middle trap
- protraction/abduction - serratus anterior
- upward rotation - upper trap, middle trap
- downward rotation - minor and major rhomboids
Name the static stabilizers of the GH joint 5
- bony congruence b/w humeral head and glenoid fossa
- glenoid labrub
- negative intraarticular pressure
- GH joint capsule
- GH ligaments (3)
Name the dynamic stabilizers of the GH joint
- scapular stabilizers (7)
- Rotator cuff (4)
- long head of biceps tendon
Deltoid arises from (3)
- anterior clavicle
- acromion
- spine of the scapula
_____ deltoid can be injured during accelerating phase of throwing. ____ deltoid can be injured during the deceleration phase of throwing.
Anterior - acceleration
Posterior - deceleration
chronic stress fracture of the humerus might appear as ____ on radiograph?
coritcal thickening along the mid-third of the medial cortex.
in adolescent pitchers, widening of the lateral part of the physis with associated sclerosis or cystic changes may be seen on external rotation AP films.
