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OCS prep mine > Shoulder > Flashcards

Shoulder Flashcards

1
Q

signs of suprascapular nerve impingement

A
  • scalloping over infraspinous fossa
  • impingement at suprascapular notch (supraspin and infraspin weakness) and spinoglenoid notch (infraspin only), paralabral cyst formation common in ppl c superior labral lesions
  • occasional numbness at lateral shoulder
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2
Q

suprascapular nerve - roots, muscles, sensory

A

C5-C6
supraspin, infraspin
lateral shoulder sensation in a small % of ppl

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3
Q

flip sign

A

resisted ER leads to medial border lifting

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4
Q

MMT for supraspinatus

A

scaption to 90 deg (full or empty can)

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5
Q

MMT for infraspinatus

A

IR of 45 deg

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6
Q

MMT of teres minor

A

90 deg scaption, 90 deg ER

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7
Q

MMT of subscapularis

A

HBB

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8
Q

muscles that get cut for TSA

A

deltopectoral approach:

  • deltoid retracted laterally
  • subscap release with tendon incision or osteotomy,
  • regional capsule release,
  • upper 1-1.5cm of pectoralis major tendon may be released (for greater exposure or IR contracture)
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9
Q

where does the humerus get cut for TSA

A

anatomical neck with 30 deg retroversion

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10
Q

what happens to the glenoid in a HA

A

left unaltered if appropriate version, otherwise concentric reaming may be needed to normalize

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11
Q

what happens to the glenoid in a TSA?

A

glenoid resurfacing with polyethylene component

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12
Q

what happens to the LH biceps tendon

A

tenodesed or tenotomy

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13
Q

tissue balancing during TSA

A
  • humeral head should sublux 50% posteriorly
  • subscap should allow min of 30-40 deg ER
  • sometimes posterior capsule shift (tightening) is needed
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14
Q

average elevation of the sh after TSA? after HA? With RA?

A

TSA 131-145
HA 117
RA103-119

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15
Q

which provides better outcomes: TSA or HA?

A

TSA

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16
Q

what percent of ppl with OA have RCT

A

9% but there is mod to severe fatty degeneration of infraspinatus. lower scores and elevation with subscap fatty degeneration.

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17
Q

what does a biceps tenodesis usually help with with a TSA?

A

pain relief

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18
Q

what percent of ppl with RA have a full thickness RCT?

A

24-30%

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19
Q

elevation following HA following fx
ER
IR

A

average 100
15-24
L4-L1

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20
Q

precautions following HA following fx

A

avoid too much passive ER (50 deg) can disrupt fx healing

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21
Q

incidence of nerve lesions following proximal humerus fx

A

67%

axillary n most common

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22
Q

progression of HA if greater tuberosity is spared vs if osteotomy is required

A

AROM 6 wks
Strengthening 12 wks
osteotomy: AROM 12 wks

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23
Q

osteonecrosis is associated with which conditions?

A

fractures, steroid use, alcohol, cushing disease

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24
Q

bursal side (superior) RC tears are the result of

A

subacromial impingement

primary and secondary compressive disease

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25
Q

partial thickness tears on the undersurface of the articular side of the RC are associated with:
which pts:

A

tensile loads and GHJ instability

throwing athletes with anterior instability, capsular/labral insufficiency

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26
Q

size of small tear:
medium tear:
large tear:
massive tear:

A

small <1cm
medium 1-3cm
large 3-5cm
massive >5

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27
Q

following RC tear of supraspinatus, early ER and IR PROM is performed in which plane

A

scapular to dec tensile load in repaired tendon

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28
Q

effect of cross arm adduction at 60 deg elevation

A

no inc in strain at the supra or infraspinatus

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29
Q

pulley vs supine flexion activities in supraspinatus activation

A

greater in pulley

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30
Q

RC activation during codman - can this be passive?

A

minimal activity but not passive

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31
Q

codman with weight in hand

A

could increase anterior translation but no change in RC activation

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32
Q

rehab following RC repair - first 2-4 weeks

A

passive and minimally active or active assisted exercises

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33
Q

dislocation means:

subluxation means:

A
  • complete separation of the articular surfaces

- excessive translation of humeral head on glenoid in association with sxs, not a complete separation

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34
Q

define instability

A

excessive symptomatic translation of the humeral head relative to the glenoid when stress is applied

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35
Q

benefits of arthroscopic instability repair over open procedures

A

less surgical morbidity, equal healing rates and outcomes

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36
Q

following instability repair, what plane should the pt be working in?

A

scapular plane to dec stress on anterior capsule, increases bony congruency. later, move into coronal plane.

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37
Q

following instability repair, which planes are usually ok for physio ROM?

A

flexion, scaption, horiz add, IR

38
Q

following plication what motions may be restricted

A

ER or IR

39
Q

what is plication?

A

removing capsular redundancy by creating a fold in capsular tissue

40
Q

gold standard tx for anterior instability

A

open bankart - restores tension to the anteroinferior capsule and inferior GH ligament complex, fixes labrum

41
Q 
surgical interventions of SLAP lesions 
I
II
III
IV
A

I debridement (or conservative)
II repair biceps anchor attachment
III debridement of bucket handle type tear
IV same as III, biceps anchor repair, biceps tenodesis or tenotomy

42
Q

which ligaments are injured with AC joint separation

A

acromioclavicular and CC ligaments (conoid and trapezoid)

43
Q

AC joint ligaments provide stability in which plane?

CC ligaments provide stability in which plane?

A

AP

vertical stability

44
Q

AC jt separation types
I
II
III

A

I sprain without tear
II rupture of AC capsule and ligs without injury to CC
III complete rupture of AC and CC ligs = step off due to acromion depression.

45
Q

imaging for AC jt

A

AP, IR and ER, scapular Y, axillary
stryker notch view may be taken in a complete AC dislocation if the normal CC interval is maintained. indicating a possible fractured coracoid process.

46
Q

which AC jt separation types usually require nonoperative tx

A

I and II

trial with III for at least 3 mo

47
Q

nonoperative tx for AC jt injury

A

I and II

1) NSAIDs, PT, possible injection, immobilization, AAROM in low positions
2) when 75% ROM –> full ROM, strengthening without bench press/military press
3) strengthening into provocative positions
4) sport specific

48
Q

when is sx considered for type III AC jt injury initially?

A
  • thin pts with significant visual deformity.
  • sustained or repetitive sh level positioning
  • lift heavy weights
49
Q

what to do with type III AC jt injury?

A

lack of evidence to support sx
immobilization time and return to work/sport is quicker with conservative tx
greater pain satisfaction with sx

50
Q

association between chronic type III AC jt injury and CS?

A

increased cervical hypolordosis and increased C/S symptoms with ACJ injury

51
Q

AC jt conservative tx should emphasize which muscle

A

upper trapezius activation and endurance

52
Q

how long is the protective phase for AC jt sx?

A

4-6 wks with a sling

pt can do pendulums, AAROM in all planes

53
Q

3 phases of AC jt sx rehab

A

1) 0-4wk protective using a sling and firm pillow
2) 4-12 wks gradual return of motion, avoid strengthening >90 deg elevation
3) 12-24 wks return to sport

54
Q

frozen shoulder affects what % of gen pop?

ppl with DM and thyroid disease

A
  1. 35-5%

10. 8-38

55
Q

typical age of frozen shoulder

A

40-65yo

females > males

56
Q

etiology of frozen shoulder

A

elevated serum cytokine levels (growth factors) causing fibrosis in the capsuloligamentous complex (CLC)

57
Q

Rotator cuff interval - what is it?

A

forms the triangular shaped tissue between anterior supraspinatus tendon and upper subscap border.
including superior GH lig and coracohumeral lig.

anterior superior hammock restricting ER and preventing inferior translation

58
Q

primary frozen shoulder

A

not associated with a particular systemic condition or hx of injury

59
Q

secondary frozen shoulder
systemic
extrinsic
intrinsic

A

systemic - DM, thyroid disease
extrinsic - MI, cervical disc disease
intrinsic - RC/biceps tendinopathy

60
Q

typical ROM findings in frozen sh
elevation
ER
capsular pattern

A

<120 with scapular substitution
50% or <30
limitations in ER > abd > IR

61
Q

typical strength deficits in people with frozen sh

A

IR, elevation

62
Q

modalities that may be effective with frozen sh

A

moist heat
short wave diathermy with stretching
TENS with low load stretch
no US!

63
Q

when should corticosteriod injections be used for frozen sh?

A

first 3-6 wks of intervention

64
Q

benefit of corticosteriod use for frozen sh

A

no differences long term

hastening the time to achieve end range fibrotic tissue by decreasing discomfort at rest

65
Q

what percent of pts undergo MUA for frozen sh?

A

7-10%

66
Q

secondary OA definition

A

posttraumatic and postsurgical (intraarticular fx or capsulorraphy)

67
Q

inflammatory arthritis includes

A

RA, ankylosing spondylitis, psoriatic arthritis

68
Q

potential causes for AVN or autraumatic osteonecrosis

A

corticosteroid use, alcoholism, gaucher disease, sickle cell, irradiation

69
Q

how do you gain access to GHJ with shoulder arthroplasty?

A

deltopectoral incision,
subscap release at tendon or osteotomy of lesser tuberosity
upper pec major can be released if IR contracture

70
Q

osteotomy of the humerus is made where for sh arthroplasty?

A

anatomic neck - 30 deg retroversion

71
Q

sh arthroplasty - soft tissue balancing

A

sh is reduced, posterior translation should sublux the humerus 50% of its diameter
minimum of 30-40 deg ER

72
Q

how much ER should the subscap allow during shoulder arthroplasty?

A

30-40 deg

73
Q

what can be done if the posterior capsule is too lax during shoulder arthroplasty? consequences?

A

larger humeral head can be used

may compromise subscap length, then they do a capsular shift

74
Q

prognosis for ppl with RA following TSA

A

poor due to less robust RC tissue compaired to primary OA - 24-30% have full thickness RC tear

75
Q

are the lift off and abdominal compression tests reliable for subscap rupture assessment following arthroplasty?

A

no

76
Q

what is the RC integrity of ppl with primary OA of the shoulder?

A

pretty good, therefore, good dynamic stabilization after TSA
- only 9% had RC tears - all in supraspinatus and repairable

77
Q

which provides better outcomes? TSA or HA?

A

TSA

78
Q

benefit of biceps tenodesis with shoulder arthroplasty

A

pain relief

79
Q

effect of RA on sh elevation following TSA

average ROM TSA 2/2 RA

A

less active elevation

~100, 47 ER, IR L4

80
Q

HA following acute fracture precautions

A

avoid too much passive ER - 50 deg

81
Q

can people perform above shoulder activities following HA due to acute fx?

A

50% can

82
Q

incidence of nerve lesions following acute sh fx - which nerves

A

axillary is most often affected

83
Q

when can AROM be started after HA following TSA due to chronic fx arthritis

A

if greater tuberosity has been spared - 6 wks

if greater tuberosity osteotomized - 12 weeks

84
Q

which outcomes are better:

arthroplasty due to osteonecrosis following steroid use or trauma?

A

steroid use

85
Q

your pt has hx of posterior instability prior to TSA - what should you consider with elevation stretching?

A

scapular plane versus saggital plane to decrease tension on posterior capsule

86
Q

if subscap was altered with a Z plasty or augmented with a graft, when may strengthening start?

A

12 weeks

87
Q

criteria for standard goals group for TSA

A

competent RC and deltoid
adequate bone quality
stable joint

88
Q

criteria for limited goals group for TSA

A

instability
RC/deltoid deficiency
tuberosity malposition
denervation

89
Q

expected elevation and ER of limited goals

A

elevation <90 deg

ER 20

90
Q

standard goals examples

A 
OA
RA with intact RC
osteonecrosis
acute proximal head fx
posttraumatic without greater tuberosity osteotomy
capsulorraphy arthroplasty
91
Q

limited goals examples

A

RC arthropathy
RA with RC tear - irreparable
acute prox humeral head fx with migration
greater tuberosity osteotomy
septic arthritis
capsulorraphy arthroplasty with instability

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