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
2
Q
suprascapular nerve - roots, muscles, sensory
A
C5-C6
supraspin, infraspin
lateral shoulder sensation in a small % of ppl
3
Q
flip sign
A
resisted ER leads to medial border lifting
4
Q
MMT for supraspinatus
A
scaption to 90 deg (full or empty can)
5
Q
MMT for infraspinatus
A
IR of 45 deg
6
Q
MMT of teres minor
A
90 deg scaption, 90 deg ER
7
Q
MMT of subscapularis
A
HBB
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)
9
Q
where does the humerus get cut for TSA
A
anatomical neck with 30 deg retroversion
10
Q
what happens to the glenoid in a HA
A
left unaltered if appropriate version, otherwise concentric reaming may be needed to normalize
11
Q
what happens to the glenoid in a TSA?
A
glenoid resurfacing with polyethylene component
12
Q
what happens to the LH biceps tendon
A
tenodesed or tenotomy
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
14
Q
average elevation of the sh after TSA? after HA? With RA?
A
TSA 131-145
HA 117
RA103-119
15
Q
which provides better outcomes: TSA or HA?
A
TSA
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.
17
Q
what does a biceps tenodesis usually help with with a TSA?
A
pain relief
18
Q
what percent of ppl with RA have a full thickness RCT?
A
24-30%
19
Q
elevation following HA following fx
ER
IR
A
average 100
15-24
L4-L1
20
Q
precautions following HA following fx
A
avoid too much passive ER (50 deg) can disrupt fx healing
21
Q
incidence of nerve lesions following proximal humerus fx
A
67%
axillary n most common
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
23
Q
osteonecrosis is associated with which conditions?
A
fractures, steroid use, alcohol, cushing disease
24
Q
bursal side (superior) RC tears are the result of
A
subacromial impingement
primary and secondary compressive disease
25
partial thickness tears on the undersurface of the articular side of the RC are associated with:
which pts:
tensile loads and GHJ instability
| throwing athletes with anterior instability, capsular/labral insufficiency
26
size of small tear:
medium tear:
large tear:
massive tear:
small <1cm
medium 1-3cm
large 3-5cm
massive >5
27
following RC tear of supraspinatus, early ER and IR PROM is performed in which plane
scapular to dec tensile load in repaired tendon
28
effect of cross arm adduction at 60 deg elevation
no inc in strain at the supra or infraspinatus
29
pulley vs supine flexion activities in supraspinatus activation
greater in pulley
30
RC activation during codman - can this be passive?
minimal activity but not passive
31
codman with weight in hand
could increase anterior translation but no change in RC activation
32
rehab following RC repair - first 2-4 weeks
passive and minimally active or active assisted exercises
33
dislocation means:
| subluxation means:
- complete separation of the articular surfaces
| - excessive translation of humeral head on glenoid in association with sxs, not a complete separation
34
define instability
excessive symptomatic translation of the humeral head relative to the glenoid when stress is applied
35
benefits of arthroscopic instability repair over open procedures
less surgical morbidity, equal healing rates and outcomes
36
following instability repair, what plane should the pt be working in?
scapular plane to dec stress on anterior capsule, increases bony congruency. later, move into coronal plane.
37
following instability repair, which planes are usually ok for physio ROM?
flexion, scaption, horiz add, IR
38
following plication what motions may be restricted
ER or IR
39
what is plication?
removing capsular redundancy by creating a fold in capsular tissue
40
gold standard tx for anterior instability
open bankart - restores tension to the anteroinferior capsule and inferior GH ligament complex, fixes labrum
41
```
surgical interventions of SLAP lesions
I
II
III
IV
```
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
which ligaments are injured with AC joint separation
acromioclavicular and CC ligaments (conoid and trapezoid)
43
AC joint ligaments provide stability in which plane?
| CC ligaments provide stability in which plane?
AP
| vertical stability
44
AC jt separation types
I
II
III
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
imaging for AC jt
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
which AC jt separation types usually require nonoperative tx
I and II
| trial with III for at least 3 mo
47
nonoperative tx for AC jt injury
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
when is sx considered for type III AC jt injury initially?
- thin pts with significant visual deformity.
- sustained or repetitive sh level positioning
- lift heavy weights
49
what to do with type III AC jt injury?
lack of evidence to support sx
immobilization time and return to work/sport is quicker with conservative tx
greater pain satisfaction with sx
50
association between chronic type III AC jt injury and CS?
increased cervical hypolordosis and increased C/S symptoms with ACJ injury
51
AC jt conservative tx should emphasize which muscle
upper trapezius activation and endurance
52
how long is the protective phase for AC jt sx?
4-6 wks with a sling
| pt can do pendulums, AAROM in all planes
53
3 phases of AC jt sx rehab
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
frozen shoulder affects what % of gen pop?
| ppl with DM and thyroid disease
2. 35-5%
| 10. 8-38
55
typical age of frozen shoulder
40-65yo
| females > males
56
etiology of frozen shoulder
elevated serum cytokine levels (growth factors) causing fibrosis in the capsuloligamentous complex (CLC)
57
Rotator cuff interval - what is it?
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
primary frozen shoulder
not associated with a particular systemic condition or hx of injury
59
secondary frozen shoulder
systemic
extrinsic
intrinsic
systemic - DM, thyroid disease
extrinsic - MI, cervical disc disease
intrinsic - RC/biceps tendinopathy
60
typical ROM findings in frozen sh
elevation
ER
capsular pattern
<120 with scapular substitution
50% or <30
limitations in ER > abd > IR
61
typical strength deficits in people with frozen sh
IR, elevation
62
modalities that may be effective with frozen sh
moist heat
short wave diathermy with stretching
TENS with low load stretch
no US!
63
when should corticosteriod injections be used for frozen sh?
first 3-6 wks of intervention
64
benefit of corticosteriod use for frozen sh
no differences long term
| hastening the time to achieve end range fibrotic tissue by decreasing discomfort at rest
65
what percent of pts undergo MUA for frozen sh?
7-10%
66
secondary OA definition
posttraumatic and postsurgical (intraarticular fx or capsulorraphy)
67
inflammatory arthritis includes
RA, ankylosing spondylitis, psoriatic arthritis
68
potential causes for AVN or autraumatic osteonecrosis
corticosteroid use, alcoholism, gaucher disease, sickle cell, irradiation
69
how do you gain access to GHJ with shoulder arthroplasty?
deltopectoral incision,
subscap release at tendon or osteotomy of lesser tuberosity
upper pec major can be released if IR contracture
70
osteotomy of the humerus is made where for sh arthroplasty?
anatomic neck - 30 deg retroversion
71
sh arthroplasty - soft tissue balancing
sh is reduced, posterior translation should sublux the humerus 50% of its diameter
minimum of 30-40 deg ER
72
how much ER should the subscap allow during shoulder arthroplasty?
30-40 deg
73
what can be done if the posterior capsule is too lax during shoulder arthroplasty? consequences?
larger humeral head can be used
| may compromise subscap length, then they do a capsular shift
74
prognosis for ppl with RA following TSA
poor due to less robust RC tissue compaired to primary OA - 24-30% have full thickness RC tear
75
are the lift off and abdominal compression tests reliable for subscap rupture assessment following arthroplasty?
no
76
what is the RC integrity of ppl with primary OA of the shoulder?
pretty good, therefore, good dynamic stabilization after TSA
- only 9% had RC tears - all in supraspinatus and repairable
77
which provides better outcomes? TSA or HA?
TSA
78
benefit of biceps tenodesis with shoulder arthroplasty
pain relief
79
effect of RA on sh elevation following TSA
| average ROM TSA 2/2 RA
less active elevation
| ~100, 47 ER, IR L4
80
HA following acute fracture precautions
avoid too much passive ER - 50 deg
81
can people perform above shoulder activities following HA due to acute fx?
50% can
82
incidence of nerve lesions following acute sh fx - which nerves
axillary is most often affected
83
when can AROM be started after HA following TSA due to chronic fx arthritis
if greater tuberosity has been spared - 6 wks
| if greater tuberosity osteotomized - 12 weeks
84
which outcomes are better:
| arthroplasty due to osteonecrosis following steroid use or trauma?
steroid use
85
your pt has hx of posterior instability prior to TSA - what should you consider with elevation stretching?
scapular plane versus saggital plane to decrease tension on posterior capsule
86
if subscap was altered with a Z plasty or augmented with a graft, when may strengthening start?
12 weeks
87
criteria for standard goals group for TSA
competent RC and deltoid
adequate bone quality
stable joint
88
criteria for limited goals group for TSA
instability
RC/deltoid deficiency
tuberosity malposition
denervation
89
expected elevation and ER of limited goals
elevation <90 deg
| ER 20
90
standard goals examples
```
OA
RA with intact RC
osteonecrosis
acute proximal head fx
posttraumatic without greater tuberosity osteotomy
capsulorraphy arthroplasty
```
91
limited goals examples
RC arthropathy
RA with RC tear - irreparable
acute prox humeral head fx with migration
greater tuberosity osteotomy
septic arthritis
capsulorraphy arthroplasty with instability
