Shoulder and Elbow Flashcards
the shoulder is actually 4 separate but related articulations. name them.
- sternoclavicualr joint
- scapulothoracic joint
- acromioclavicular joint
- glenohumeral joint.
outline which structures make up the skin, muscle/tendon/bursa, capusle/ligaments, cartilage, and bones of the STERNOCLAVICULAR JOINT.
outline which structures make up the skin, muscle/tendon/bursa, capusle/ligaments, cartilage, and bones of the ACROMIOCLAVICULAR JOINT
outline which structures make up the skin, muscle/tendon/bursa, capusle/ligaments, cartilage, and bones of the GLENOHUMERAL JOINT
outline which structures make up the skin, muscle/tendon/bursa, capusle/ligaments, cartilage, and bones of the SCA{ULOTHORACIC ARTICULATION
there is no cartilage or synovium– it’s muscle on muscle.
Fill out this table
treatment for ANTERIOR sternoclavicular joint fracture
- caused by posterior force to shoulder
- treated with RICE and sling. pretty benign, sometimes may have some OA later.
treatment for POSTERIOR sternoclavicular dislocation
caused by anterior force to shoulder
- this is an emergency because it may have injured the mediastinum.
- needs a reduction, maybe open surgery.
treatment for medial physis fracture of SC joint
younger patient.
Swelling and Pain over SC
dp XR
Sling, RICEimplications depend on situation.
dislocations.usually heals, physis ossifies at 25
if a person is under 25 with an SC joint injury, what is the first type of injury you should suspect?
physis fracture– it isn’t fully ossified yet
clavical fracture. candidate surgery because of severe malunion– you can’t even reset that at that point.
treatment for clavical injuries
Sling, RICE (for closed)
surgery for opened or previous and painful nonunion.
Common injuries
• Most do well with non-op
Rx
which joint is being injured here?
the AC joint. usually they do well with RICE and physio
difference between Types 1 and 2, and Types 3/4
types 1/2= AC ligaments injured.
types 3/4 AC and CC ligaments ruptured.
All treated with sling, RICe and periscapular rehap. operation for failed non-op treatment.
when would the AC joint have an emergency orthopedic resolution
when the clavical gets stuck under the coracoid and gets all twisted. extremely rare and weirdly disfigured/painful.
A ____lesion, or ____ fracture, is a cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.
A ___ lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
A HILL SACHS LESION, or HS fracture, is a cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.
A BANKART lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
occurs in anteiror GH joint dislocation,
two kinds of shoulder stabilizers
static and dynamic
statuc; active constantly, not adaptive to a situation
dynamic; active on demand, adaptive to a situation
examples of static and dynamic stabilzers of the shoulder
if a damaged static stabilizer in the shoulder occurs, it can be fixed by ___. if a damaged dynamic stabilizer (ex/ RC muscles), then it can be fixed by ___
if a damaged static stabilizer in the shoulder occurs, it can be fixed by SURGICAL RECONSTRUCTION. if a damaged dynamic stabilizer (ex/ RC muscles), then it can be fixed by REHABILITATION
note: this is a normal GH joint and AC joint placemnet.what does a break in shenton’s line indicate?
a break in shentons line may indicate an anterior dislocation of GH joint.
in a posterior GH joint dislocation, the articular surfaces are OVERLAPPING, but shenton’s line is kinda intact
note:GH joint dislocations are the most common shoulder dislocations. often times for 1st time offenders all you need is sling and rehab for both anterior or posterior issues.
make sure to get an adequate radiograph after reduction and neurovascular exam
note: after the age of 50, GH joint dislocation may be on the differnetial for shoulder pain, but you should really suspect rotator cuff injuries
T/F surgery often corrects proximal humerus fracturs
false. most do not do better with surgery. start with a sling and adequate analgesia. talk about bone health. these can be very painful for several weeks.
Shoulder injruy DDX if nothing shows up on Xray (no breaks or dislocations)
Soft tissue injury
- adhesive capsultiis
- subacromial bursitis
- calcific tendinopathy
- rotator cuff disease (long head of biceps primarily affected)
3 phases of adhesive capsultiis
ROM characteristics of subacromial bursitis
3 phases of AC:
- freezing– progressive stiffness
- frozen– painful to move in any direction, both active and passively
- thawing.
for subacromial bursitis; better PROM and AROM
condition where the body starts depositing calcium in the RC tendon
calcific tendinopathy. resolves over time.
muscles of the RC cuff
Subscapularis.
Infraspinatus.
Supraspinatus.
Teres minor.
the rotator cuff in innervated by c__ and c__- roots
the supraspinatus (SS) and in the infraspinatus (IS) is innervated byt eh ___ nerve
the subscapularis (SSc) is innervated by the __ nerve
the Teres minor (TM is innervated by the ___ nerve.
the rotator cuff in innervated by C5 and C6- roots
the supraspinatus (SS) and in the infraspinatus (IS) is innervated byt eh SUPRASCAPULAR NERVE
the subscapularis (SSc) is innervated by the UPPER/LOWER SUBSCAPULAR NERVE
the Teres minor (TM is innervated by the AXILLARY nerve.
individual functions of
SS
IS/TM
SSc
What do they collectively do?
collectively, they eep the humerus on the glenoid and they resist upward pull of the deltoid.
which RC muscles are first affected in a RC injury?
typically begins with Super Spinatus, and moves posterior to the IS or anterior to the Ssc (less common)
When there is a RC injury, the ___ ___ of the ___ can sometimes degenerate.
long head of the biceps.
how does smoking and diabetes make orthopedic surgery higher risk
we try and treat rotator cuff without operations, but who might be a good candidate for an RC surgical consult?
younger, higher demand (manual laborer), or large tear size
whats going on to this shoulder?
glenohumeral osteoarthritis
- calssic OA symptoms on radiograph:
1. reduced joint space
2. subchondral sclerosis
3. osteophytes
subchondral cysts
usually: the most efficiency and resource-effective imaging is a combo of good x-rays and an ultrasound interpreted in context of history and physical exam.
what other scan should be added if pt is having a surgery
Add a CT scan if patient is having surgery.
Using an MRI to diagnose arthrosis already visible on a radiograph is a bad use of resources.
for shoulder arthritis, the state of the RC dictates the clinical features and the treatment. there will be more erosion of the GH joint and the AC joint if the RC cuff is failing. Patients do not typically gain ROM with the replacemnet, but the pain of the arthritis is alleciated.
in the elbow there are 3 articulations. outline
- capitulum and head of radius
- trochlea of humerus and trochlear notch of ulna
- head of radius articulates with radial notch of ulna.
fill in the table for the layers of the elbow
muscles originating on the lateral epicondyle of the humerus and running down the dorsal forarm usually act as _____ for the digits and wrists.
muscles on the medial epicondyle of humerus and running down the volar forearm produce flexion of wrists and digits and _____ of the forearm
muscles originating on the lateral epicondyle of the humerus and running down the dorsal forarm usually act as extensors for the digits and wrists.
muscles on the medial epicondyle of humerus and running down the volar forearm produce flexion of wrists and digits and pronation of the forearm
humeral SHAFT fractures are often a result of a FOOSH injury. which nerve is compromised in a humeral shaft fractyre?
the radial nerve can pose a huge implication. must documetn clear NV exam before and after any maneuvers. the radial nerve supplies the triceps, extensor compartment of the forearm and deficits in this nerve can result in a wrist drop, inability to exnt fingers, numbness along radial forarm
main treatment for humerus fracture (not open)
a sling.
a DISTAL humeral fracture can also be caused by a FOOSH injury. usually higher energy than a humeral shaft fracture. which nerve is compromised?
the ulnar nerve: supplies hand intrinsic muscles, some finger and wrists flexros, and sensation to ulnar 1.5 digits.
T/F a distal humeral fracture can be splinted if closed
false. unike a closed humeral shaft fracture, almost all distal humeral fractures require surgery with open reduction and internal fixation. sometimes a total elbow replacement, which sucks cause it often significantly reduces range of motion.
note;
how are olecranon fractures mostly fixed
almost always fixed surgicall.
examples of static and dynamic stabilizers of the elbow.
the elbow is MUCH MORE dependent on bony shape for stability than the shoulder. it makes it more stable to begin with and harder to dislocate without fracture.
terrible triad for elbow
combination of radial head fracture, coronoid fracture, medial/ulnar collateral ligament injury. (along with ulnarhumoral joint dislocation)
which one is a simple ulnaohumeral dislocation vs terrible triad.
top is simple- humerus has jumped over the coranoid process of the ulna –> reduce and rehab
bottom is terrible triad: humeras has exited by smashing the coranoid [rocess and fracturing the radial head. –> requires surgery
what are these two fractures and treatment?
radial head elbow dislocation. more common in kids. aka monteggia dislocation.
in both images, the radial head is not pointing to the captella.
tx; fix the ulna, and the radial head usually behaves thereafter. missed injuries can lead to substantial permanent problems.
4 muscle groups around the elbows
- flexors; biceps, brachialis, brachioradialis
- extensors; triceps
- common extensor orgiin
- common flexor origin.
- if the person can range the elbow on passive motion but it hurts, it’s probably a soft tissue muscle rupture (ex/ person holding a heavy load, feels sudden pop and pian in front of elobw–> probably a distal bicep rupture)
the only muscle tha tdoes flexion and supination is the ___
biceps.
a person was carrying a heavy load in their arms and felt a pop. on exam, elbow flexion is weak, and they can’t supinate. however, they can extend their elbow. which muscle is most liekyl affected?
the bicep. the fact that they can extend their elbow joint indictes that the tricpes is intact.
which sex is affected most by distal bicep tendon rupture
M>>F. due to eccentric loag on the elbow (flexion contraction while too much weight pulls to extension)
fill in this chart for epicondylitis
most common tendinopathy in elbow
epicondylitis either of the medial or lateral common flexor or common extensor tendons.
medialepicondylitis = common flexor = golfer’s tendonitis
lateral elbow epicondylitis = common extensor = tennis elbow
