PC Shoulder Flashcards
Primary blood supply to humerus
Posterior Humeral cicumflex
Terminal branch of anterior humeral circumflex
Arcuate artery is terminal branch of anterolateral ascending branch of AHCA
Humeral normal neck shaft angle
130 degrees
Retroversion 30 degrees relative to transepicondylar axis
Dynamic stabilizers of the glenohumarl joint
Rotator cuff (concavity comprssion) Scapular stabilizers
Static stabilizers of glenohumeral joint
Labrum (increases depth up to 50%) Articular version Capsule Glenohumeral ligaments Negative intraarticular pressure
Angle of glenoid relative to scapula
5 degrees retroversion
5 degrees upward tilt
Superior glenohumeral ligament
Resists anterior translation of adducted arm
Middle glenohumeral ligament
Resists anterior translation of arm at 45 deg abduction & ER
Anterior band of IGHL
Resistes anterior-inferior translation of arm at 90 deg abduction & ER
Posterior band of IGHL
Resists posterior-inferior translation in IR and ADDuction
Relative proportion of shoulder motion from glenohumeral joint & scapulothoracic joints
2/3 glenohumeral
1/3 scapulothoracic
First 30 degrees is GLENOHUMERAL only
Timing of clavicle ossifiation to close
Age 20-25
Bleeding occurs when taking down coracoarcomial ligament too medially
Acromial branch of thoracoacromial artery
Most common site of symptomatic Os Acromiale
Junction of meso and meta-acromion
3% incidence
60% bilateral
Relative alignment of CC ligaments
Conoid – medial — bigger and stronger
Trapezoid – lateral
Rotator interval
Between subscapularis and SGHL
Laxity of rotator interval causes
Multidirectional instability
Causes inferior translation
Contraction of rotator interval causes
Decreased ROM — think adhesive capsulitis
Describe regions of the axillary artery & how we split it up
Divided into 3 revions by pectoralis minor muscle
Part I - medial to pec minor – superior thoracic artery
Part II – deep to pec minor — lateral thoracic trunk, throacoarcomial trunk
Part III – lateral to pec minor – anterior humeral circumflex artery, posterior humeral circumflex, subscap artery
Blood supply of anterior humeral circumflex artery
Humeral head
Blood supply of posterior humeral circumflex artery
Posterior greater tuberosity & posteroinferior head
Course of axillary nerve
Passes through quadrilateral space with posterior humeral circumflex
Posterior branch terminates as sensory branch to lateral arm and motor to teres minor
Anterior branch innervates undersurface of deltoid
Define the Triangular Space
Borders: teres minor, teres major, long head of triceps
Contains: Scaular circumflex artery
Define the Triangular Interval
Borders: teres major, long head of triceps, humerus
Contains: Radial nerve, profunda brachii artery
Terminal branch of musculocutaneous nerve
Lateral antebrachial cuteanous nerve
Course of musculocutaneous nerve
Comes off **
Penetrates coracobrachialis 3-8 cm distal to tip of coracoid
Innervates biceps and brachialis
Terminates of LACN
Innervation of subscarpularis
Upper & lower subscapular nerves
Function & innervationof Latissimus dorsi
Extension, IR, Adduction
Innervation: Thoracodorsal nerve
Function & innervation of teres major
Extension, Adduction
Innervation: lower subscapular nerve
Distance of axillary nerve from lateral acromion
7 cm
Radiographic view of the shoulder that best reveals a Hill-Sachs lesion:
Internal rotation AP
Scapular winging direction
Inferioer pole points to the direction of winging
MEDIAL winging -> long thoracic nerve (serratus anterior palsy)
LATERAL winging -> CN XI (trapezius palsy)
Complication seen in general surgical excision of thryoglossal cyst
Spinal accessory nerve injury -> trapezius injury -> lateral scapular winging
Treatment of acute medial scapular winging
Acute < 3 mos
PT for strengthening of periscapular muscles
Treatment of chornic symptomatic medial scapular wining
Split pectoralis transfer with autologous hamstring
Treatment of acute lateral scapular winging
Acute < 3 mos
PT for strengthening of periscapular muscles
Treatment of chronic lateral scapular winging
Transfer of levator and rhomboids laterally
Thoracic outlet syndrome
Compression of the brachial plexus and subclavian btw scalenes & first rib
Have pain and ulnar paresthesias
Look for:
Cervical rib
Scapular ptosis
Scalene muscle abnormality
Quadrilateral space
Borders: teres minor, teres major, long head of triceps, humerus
Contents: Axillary nerve, Posterior humeral circumflex artery
Transient pain and paresthesias down the arm in weight lifter or pitcher:
Quadrilateral space syndrome
Get compression from arm in abduction, extension, and 90 deg ER with hypertrophy of the adjacent muscles
Affects Axillary nerve & PHCA
Tx: release the adjacent fascia
Suprasapular nerve
Comes off upper trunk of brachial plexus
5th/6th cervical nerve roots
Mixed motor & sensory nerve
Motor: supraspinatus/infraspinatus
Sensory: AC joint; capsule/ligamentous structures
Sites of compression of suprascapular nerve
Transverse scapular ligament
Spinoglenoid ligament –> isolated infraspinatus atrophy
Most common brachial plexus nerve injury in athletes:
Suprascapular nerve entrapment
Pectoralis major tendon ruptures
Weight lifters – BENCH PRESS
Avulsion of tendon off insertion
Loss of chest contour & axillary fold
MUST directly repair to bone (for chronic, use SemiT augmentation)
Innervation of pectoralis major:
Medial pectoral nerve & lateral pectoral nerve
Insertion of pectoralis major:
Greater tuberosity, lateral to the long head of the biceps
Insertion of teres major:
Greater tuberosity, medial to the long head of the biceps
Biceps tendon is the “Lady between 2 Majors”
Treatment of biceps tendonosis:
PT, PT, PT
NSAIDs, injection
injection
Surgical treatment
Long head of biceps tendon out of the groove
Think subscap tear
Biceps tenodesis is superior to tenotomy in what way?
Lower popeye deformity rate
Position of arm for lateral decubitus shoulder scope:
10-15 lbs traction
35-45 deg abduction; 15 deg forwards flexion
Avoid 70 deg abd and 30 deg flexion – to avoid injury to brachial plexus
Most common shoulder problem after interscalene regional anesthesia:
Anterior interosseous nerve palsy
Most common nerve(s) injured from posterior shoulder portal:
Axillary nerve - posterior branch (12.4 mm from glenoid rim; 2.5 mm from IGHL at 6 pm)
Suprascapular nerve
Posterior circumflex humeral artery
Most common nerve injured with anterior shoulder portal
musculocutaneous nerve
History in SLAP tear
Pain, clicking
Dead arm
Decreased throwing velocity or distance
Sensitivity/Specificity of SLAP
Sens 47-100
Spec 31-99
Not that good
Classification of SLAP tears
1: degeneration/irregular at surface
2: torn anterior to posterior; pulled off supraglenoid tubercle
3: torn/detached from biceps; bucket handle tear
4: torn & propagated to biceps with bucket handle tear
Treatment for type I SLAP
Debride
Treatment for type II SLAP
Repair with sutures
Treatment for type III SLAP
Debride
Treatment for type IV SLAP
Repair with sutures; Biceps tenodesis
Normal anatomic variants that look like SLAP tear
Buford complex — cordlike thickening of MGHL
Sublabral foramen
DON’T FIX!!
Bankart lesion
Detachment of anteroinferior labrum and IGHL complex
Hill Sachs lesion
Humeral head impression fx
Posterolateral
HAGL
Humeral avulsion of glenohumeral ligaments
Open treatment
ALPSA
Anterior labroligamentous periosteal sleeve avulsion — labrum heals to medial glenoid neck
> 40 year old with shoulder dislocation has what injury:
Rotator cuff tear
> 50 year old with shoulder dislocation has what injury:
Greater tuberosity fracture
Associated with nerve injuy; 50% by EMG
Often has rotator cuff as well
Incidence of axillary nerve injury with shoulder dislocation
5%
Treatment of anterior shoulder instability
Brief immobilization — in ER + adduction
<16 yo —> physical therapy
Indication for early operative treatement in anterior shoulder instability
< 25 yo
Contact athlete
Bone injury and defect
Most common complications of anterior instability
RECURRENCE (age most important risk factore — 20 yo = 90%; 20-40 yo = 60%; >40 yo = 0%
Loss of external rotation
Ruptures: test subscap lift off
Treatment posterior shoulder instability:
Closed reduction — up to 3 mos
Open reduction — chornic or locked humeral dislocation with antero-superior defect; posterior shift to translate the subscap with the lesser truberosity into the lesion
Complications of posterior instability surgery:
Overtightening –> causes anterior instability
Nerve injury –> axillary or suprascap
Multidirectional instability (definition & pathology)
Global laxity — inferior + (anterior OR posterior)
PE: sulcus sign
Pathology:
- patulous inferior capsule
- Stretched bands of IGHL-Ant & Post
- Stretched rotator interval
- Ligamentous laxity
- Absent labral pathology
Treatment multidirectional instability (nonop & op)
Nonop, nonop, nonop
Surgery: inferior capsular shift +/- rotator interval closure
Complication: recurrence
Internal shoulder impingement
Throwing athlete
Compression of the posterior labrum on the posterior rim of the glenoid during extreme abduction + external rotation
PASTA = partial articulra surface tear at the junction of the supra/infraspinatus
Physical exam findings in internal impingement
GIRD — glenohumeral internal rotation deficit
Internal rotation decreased
External rotation increased
Humeral retroversion increased
Imaging:
posterior labral tear
partial articular surface tear
Bennett lesion — glenoid exostosis in the posterior capsule
Treatment GIRD
NONOP: posterior capsular stretching
if 6 mos and fail – can debriede labrum
Strongest AC ligament
Superior-posterior ligament/capsult is strongest
Coracoclavicular ligament
Trapezoid – anterolateral
Conoid – posteromedial — stronger
Zanca view
AP view with 10 degrees cephalic tilt to see AC joint
Treatment for symptomatic AC joint
Arthroscopic distal clavicle resection
MUST preserve POSTERIOR and SUPERIOR AC ligaments for AP stability
Distal clavicle osteolysis
Weight lifters; h/o trauma
XR: osteopenia/osteolysis/tapering
Tx: conservative; if fail conservative tx, then distal clavicle excision
AC joint instability classification/tx
I: AC sprain/CC intact --- nonop II: AC torn/CC sprain --- nonop III: AC torn/CC torn --- nonop vs op VI: buttonholed through trapezius --- recon V: >300% displacement --- recon VI: inferior to coracoid --- recon
Size classification of rotator cuff tears
Small 0-1cm
Medium 1-3cm
Large 3-5cm
Massive >5cm
Classification of rotator cuff atrophy
0 - Normal 1 - Fatty streaks 2 - More muscle than fat 3 - Equal fat and muscle 4 - More fat than muscle
Operative indications for rotator cuff tear
Failed conservative tx
ALL acute traumatic tears in younger pts
Elderly patients who have failed nonop tx and desire no loss of function
Contraindications for rotator cuff repair
- Glenohumeral DJD
- Fixed proximal migration
- Axillary/deltoid nerve dysfucntion
- Chronically retracted tendon/fat atrophy
- Infection
DON”T fix atraumatic tears in older folks
When do young overhead throwers get partial rotator cuff tears (Phase of throwing)?
Deceleration
Treatment of older patient with chronic rotator cuff tear, anterior escape?
Reverse TSA
Essential lesions of adhesive capsulitis
Shortened coracohumeral ligament
Contracted rotator interval
Clinical phases of adhesive capusulitis
– Freezing: painful, gradual onset
– Frozen: decreased pain, limited ROM
– Thawing: gradual return of motion
Gold standard for assessing glenohumeral arthritis
CT scan
Contraindications for total shoulder arthroplasty
- full thickness cuff tear
- Nonfunctioning deltoid
- Brachial plexopathy
- severe glenoid bone loss
Shoulder position for arthrodesis
30-30-30
F-Abd-IR
Most common reason for TSA failure
Glenoid loosening
Contraindications for reverse TSA:
- Chronic infection
- deltoid dysfuntion
- axillary neuropathy
- poor glenohumeral bone stock
Center of rotation in reverse TSA moves:
Medial and inferior — improves deltoid fulcrum
Indictions to fix clavicle fractures
> 100% displacement
2cm shortening
At risk skin
Neurovascular impingement
Treatment of clavicle fractures for boards
Nonoperative
Indications for ORIF clavicle fx
- Open fx
- subclavian artery injury
- floating shoulder
- clavicle + scapular neck fx
- type II distal clavicle fx –> high rates nonunion
Greater tuberosity fracture-dislocation — common associated injury
Axillary nerve
Vascular supply to the articular fragment in proximal humerus fractures
Posterior Humeral cicumflex
Most common complications of proximal humerus fracture ORIF
Screw penetration of articular surface (23%) Axillary nerve damange Impingement Humeral shaft fx Infection Loss of ROM Varus malreduction
How do you judge height during hemi or RTSA for 4-part proximal humerus fx
Pec major insertion –> 5 cm proximal to border
Radiograph findings in Little Leaguer Shoulder:
Widening of the physis laterally
Treatment of Little Leaguer Shoulder
No throwing x 2-3 mos
Start RC strengthening with full painless ROM
Progressive throwing program
Most common complication long term of adhesive capsulitis who completed stretching program:
Decreased ROM compared to contralateral shoulder
Associated conditions for adhesive capsulitis:
Diabetes Thyroid disorders H/o MI Chron's disease Prolonged immobilization
Average medial to lateral distance of the supraspinatus tendon at it’s insertion on the greater tuberosity
14-16 mm medial to lateral
23 mm anterior to posterior
Best approach to posterior capsule in posterior shoulder instability
An infraspinatus splitting approach
Risk factors for recurrent instability after arthroscopic bankart repair
- Age under 20
- Male
- competetive or contact sports; or forced overhead activity
- shoulder hyperlaxity
- Hill-Sachs on XR
- Loss of glenoid contour (>25%)
Factors leading to poor outcome after latissimus transfer for irreperable massive rotator cuff tear
Deficient subscap
Deficient deltoid
Stage 3/4 fatty degen of supra and infra
Structures that pass through the rotator interval
Biceps tendon
Coracohumeral ligament
Superior glenohumeral ligament
Differnece in biomechanical testing of double-row versus single-row fixation for rotator cuffs
Double row has higher ultimate tensile load strength
They have similar peak-to-peak elongation, stiffness, and conditioning elongation
Rehab program after SLAP repair
week 1-4
sling with passive forward elevation. Avoid extremes of abduction and external rotation
passive and active assisted flexion in the scapular plane
week 4-6
progress to active ROM, isometrics
week 6-12
functional exercise and light strengthening
week 12+
advance strength and ROM, sport-specifics
typical return to sport around 6 months
