Shoulder and Knee Flashcards
Gamekeeper’s/skiers thumb is injury to what liagment
ulnar collateral ligament (UCL sprain or tear)
Where are the bursas in the knee?
- suprapatellar bursa
- subcutaneous prepaterllar bursa– on top of patella
- subcutaneous infrapallar bursa
- deep infrapatellar bursa
- subsartorial (pes anserinus) bursa
- Semimembranosus bursa– behind the knee
Describe the blood distribution of the meniscus
- Blood supply comes from the outside (red zone)
- Inside part is (white zone)–> tear has a little chance of healing due to little blood supply
*Get MRI to tell location of the tear or a scope
When performing a PE of the knee/lower leg always evaluate:
- Gait evaluation
- Passive and active range of motion (ROM)
- Any obvious deformity or muscular atrophy (Vastus Medialis Oblique VMO), swelling or effusion.
- Tenderness over joint line, patellar, etc.
- Patellar tracking (lateral) and instability
- ligament instability testing
What PE tests evaluates the collateral ligaments of the knees
Valgus: push knee in and rotate leg outward= tests MCL
Varus: push knee out and rotate leg inward= tests LCL
What PE tests evaluates the cruciate ligaments of the knees
Lachman’s** (30 degree of flexion created by knee under the thigh)
Pivot shift
Anterior/posterior drawers
What PE tests evaluates the menisci of the knees
McMurrays Apley test (same as mcmurry but pt is prone not supine)
What is a normal Q angle
15-20 degrees
- valgus angulation btwn the pull direction of the quads and patella tendon
- *if increased= patella is lateralized w/ respect to center groove
how do you test patella laxity/instability
- patellar apprehension test
* increase Q angle creates instability
tx of increase Q angle/ anterior-knee pain syndrome
VMO (Vastus Medialis Oblique) strengthening
what type of x-rays do you need to ask for with OA evaluation
weight bearing
describe the x-ray views for knees
- AP
- Lateral
- Merchant view: shows if patella is tilted, if increase Q angle then you will have a tilted patella, J tracking
what is the common MOI for ACL tears
-trauma with a twisting or hyperextension force with foot planted
What is O’Donoghue’s or unhappy triad?
injury to
- meniscus
- MCL tear (or LCL but less likely)
- ACL tear
*50% of pts with ACL tears, also have meniscus injury
Presentation of ACL tear
- Acute injuries are usually associated with a rapid effusion (hemarthosis in the first 24 hrs),
- unable to weight bearing and
- feeling of a mechanical “giving away.”
- Most patients will NOT be able to ski down the hill, or walk.
Radiology findings suggestive of ACL tear
- Segund fx– LCL avulsion fx (involves the lateral aspect of the tibial plateau)
- Kissing bone edemas
- ACL avulsion tx
3 types of grafts used for ACL tear reconstruction
- Bone-tendon graft
- Hamstring tendons (semitendinosus and gracilis)** most common
- Allograft
What is a buckle-handle tear?
inner rim of the meniscus pulls away from the residual meniscal body, resulting in a longitudinal tear pattern that resembles the shape of a bucket
-meniscus flips on itself and causes mechanical locking**
What is Chondromalacia Patellae
aka patellar-femoral pain syndrome
- inflammation of the underside of the patella and softening of the cartilage
- often caused by increased Q angle which causes the patella to track laterally
tx of Grade IV Chondromalacia Patellae
Tx: can do a lateral release of patella tendon or osteotomy/unicompartment arthroplasty (MAJOR SURGERY)
Risk factors for tendon ruptures
- long term steroid use
- quinolone antibiotics (“-floxacin” meds)
- alcohol abuse
*Ask about these with all tendon ruptures
Patella alta can appear with what type of tendon rupture?
Patella baja can appear with what type of tendon rupture?
alta- patellar tendon rupture
baja- quadriceps tendon ruptures
Insall-Salvati method for determining patella alta/baja
normal: 1
Alta: over 1.2
Baja: less than 0.8
complications of a tibia fx
- genu varus deformity
- non-union
**Always check for compartment syndrome
tx for patellar fx
open reduction and internal fixation (ORIF)
what is a Bipartite patella
ongenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones instead of a single bone *usually a benign and incidental finding
tx of a knee dislocation
- true ortho and vascular surgery emergency involving multi-ligamen and neuro-vascular injury (popliteal artery/nerve)
- STAT angiogram and reduction
When someone has a chronic foot drop they need to be put in an
AFO (ankle foot orthotic)
One pound wt. lost equals __ lbs of less joint stress in people with knee OA
4lbs
**Arthritis is the most common cause of disability in the United States
When is a unilateral compartment knee replacement done
younger pts with patellar compartment and opposite lateral/medial compartment free of arthritis
What is an osteochondral defect (OCD)?
- focal area of damage that involves both the cartilage and a piece of underlying bone (results in hole in the bone from cartilage collapse)
- These can occur from an acute traumatic injury to the knee or an underlying disorder of the bone
*Painful!
tx of osteochondral defect (OCD
shave the hole or put a bone plug in (OATS procedure)
How do you reduce a patellar dislocation
Reduction: extend knee and push on it (give propofol for pain)
What is a popliteal cyst (Baker’s cysts) associated w/
degenerative meniscal tear and systemic inflammory conditions such as RA
What is a baker’s cyst
benign swelling of the semimembranosus/popliteal bursa with synovial fluid
*causes a bulge and a feeling of tightness behind your knee. The pain can get worse when you fully flex or extend your knee or when you’re active.
Most frequently dislocated joint in adults
shoulder
*most mobile joint
what do you worry about with shoulder dislocations and reductions
axillary nerve (neurovascular supply)
What DDX can cause referred shoulder pain
- MI
- pneumothorax
- cervical spine problems
- Diaphgragmatic irritation
- thoracic outlet syndrome
PE of Shoulders
- look at front and back for deformity/atropy
- AROM and PROM
- apprehension/relocation tests for multidirectional instablilty
- Special tests
what is sulcus sign associate with
inferior shoulder instability
what special tests are associated w/ anterior labrum tears
O’Brians test
what special tests are associated w/ rotator cuff injuries
- Neer’s impingement sign: pain and/or tenderness w/ forward flexion
- Hawkins: pain and/or tenderness with abduction and internal rotation in the scapular plane
- Drop arm test
what special tests are associated w/ AC joint pain
cross arm test
Scapular winging is due to
long thoracic nerve palsy
What xray views are included in a trauma series for the shoulder
AP
scapular Y
axillary view
What xray views are included for instabiliity views for the shoulder
AP
West point axillary
Stryker notch
What xray views are included in impingement studies for the shoulder
- supraspinatus outlet
2. 30 degree caudad AP
What is the money xray view shot for shoulder dislocations?
Axillary lateral view
*need image for shoulder out and in
What is the most common type of shoulder dislocation and what is the MOI
Anterior dislocation are the most common with an external rotation and abduction motion as the mechanism of injury (throwing motion).
Secondary causes of shoulder dislocations
- seizures
- electrical shock
- sport-related trauma
- MVA
What are 2 ways to perform a closed shoulder reduction?
- Traction/counter-traction technique: Longitudinal traction, with gradual abduction and external rotation until a clunk is heard and felt. (WORKS BETTER)
- Gravity-Assisted Reduction (Stimson technique) with longitudinal traction with 5-15 lbs.– good for chronic or recurrent dislocations
- Always check Neuro-Vascular function before and after reduction!!!!
- Use profolol
- *the sooner you can reduce it the better
How do you test neurovascular fxn in a shoulder dislocation
- assess feeling on deltoid and on radial side of arm (sensory)
- ask to fire the deltoid muscle (motor)
- check distal radial pulse
What is a Bankart lesion associated with?
-Is an injury of the glenoid and/or LABRUM due to anterior or posterior shoulder dislocation and it is usually an indication for surgery
After a shoulder dislocation, you should think about what 2 possible injuries?
- Bankart- labrum injury
2. Hill Sach’s fx- humerus injury
What is a Hill Sach’s fx associated with?
- cortical depression in the head of the Humerus bone.
- It results from forceful impaction of the humeral head against the Anterior-inferior glenoid rim when the shoulder is dislocated anteriorly
What muscles comprise the rotator cuff
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
*the supraspinatus as the most commonly injured (closest to acromion)
Sx of rotator cuff injuries
- impingement,
- tear,
- proximal head of biceps tendon rupture or secondary to instability.
- Could be from degenerative changes or from an acute trauma
- location of pain: anterior, lateral or superior, with lateral pain over the Deltoid as the most common location.
- Pain worse with motion at, or above shoulder level.
- tenderness over sub-acromial space, greater tuberosity of AC joing
T/F Degeneration of the rotator cuff is a part of the NORMAL aging process
True
First-time anterior shoulder dislocation in patients 40 years old or older, also have a 40-60% incidence of rotator cuff tears (RCT). You should get what imaging?
GET AN MRI–> often have dislocation + rotator cuff tear
Rotator cuff injuires impingment diagnostic ad therapeutic test
- Injection of 10cc of local anesthesia (commonly a combination of short and long acting anesthesia and a corticosteroid) in the subacromial space (not shoulder JOINT)
- may also inject AC joint but not as easy (tight joint)
*Document percentage of pain before and after injection, with pain relief of at least 50% as diagnostic for rotator cuff injury
non-surgical managment of a rotator cuff injury
- NSAIDS, ice, rest
- Cortisone injection
- activity modification
- PT for at least 3 months (US, phonophoresis, motion and RC strengthening)
surgical managment of a rotator cuff injury
- Subacromial decompression (arthroscopic or open) with bursectomy.
- Distal clavicle resection (Munford Procedure)
- Rotator cuff repair
The most common cause of an AC joint separation is
falling on the shoulder
Symptoms of an AC joint separation
- range from mild tenderness felt over the joint after a ligament sprain to
- the intense pain of a complete separation.
- Grade II and III separations can cause a considerable amount of swelling
- In grade III separations, you may feel a popping sensation due to shifting of the loose joint and usually cause a noticeable deformity on the shoulder.
PE and physical of AC joint separation
- Deformity at the AC joint
2. Xrays, weight vs non-weight baring with increased coraco-clavicular distance
What are the different grades of AC joint separations?
Grade 1- injury to capsule
Grade 2- elevation of clavicle- no ligaments torn
Grade 3- corico-clavicular ligament is torn
Treatment of AC joint separations
- Ice, rest, NSAIDs ( if no contraindications)
- 2 - 4 weeks in sling (symptomatic Rx )
- Grade III controversial for surgery vs. conservative Rx, with late sequelae of AC joint DJD as a common complication of surgical fixation.
fractures of the shoulder
- Proximal Humerus (5%)
- Mid-shaft Humerus
- Scapula
- Clavicle (5% of all fx seen in ED)
Proximal humerus fractures usually occur in what patients and from what MOI
- older pts who have osteopenic/osteoporotic and fragile bone
- ground-level fall
Treatment of proximal humerus fractures
- Most commonly treated non-operative with a sling and early range-of-motion (ROM) exercises.
- Gentle ROM exercises may begin after 7-10 days, if the fracture is stable.
- When fracture displacement occurs, operative intervention is recommended.
*The majority of fractures (about 85%) are non-displaced.
In the Neer classification of proximal humerus fractures, the proximal humerus is made up of four parts:
- humeral head (articular surface)
- greater tubercle
- lesser tubercle
- diaphysis (shaft)
*Part 4 is the worst – head loses vascular supply so need emergent surgery
types of humerus greater tuberosity avulsion fractures
- avulsion
- depression
- split
*If not displaced, we don’t tend to fix it
Most mid-shaft humerus fractures are a result of
a direct blow such as a MVA
Treatment of mid-shaft humerus fractures
- Most are treated non-operatively with close to 100% fracture union rate.
- Extremely important to assess neuro-vascular function with the RADIAL nerve as the structure at highest risk for injury.
- Radial nerve test: Cannot dorsiflex wrist? Cannot push against a hitch hiking thumb against resistance, can you feel arm
What type of brace is used for a mid-shaft humerus fracture
Sarmiento brace
*2 weeks in this brace and the bone fragments won’t move anymore
Treatment of non-displaced scapula fractures
usually treated conservatively
What is considered a “floating shoulder”
Any scapula fracture through the body, and/or extending into the glenoid fossa, or a comminuted fracture that is associated with a clavicle fracture
*considered and orthopedic emergency
**If scapular fracture goes along with a clavicle fracture is a RED FLAG!! (worry about a floating shoulder)
tx of a floating shoulder
This is an extremely unstable fracture and requires emergent arteriogram and CT scan
*first repair the artery and then repair the clavicle and scapula
Because conservative treatment of a floating shoulder may result in ___ of the shoulder girdle, a floating shoulder usually requires operative stabilization
displacement (medialization)
Associated injuries seen with a floating shoulder in up to 80-90% of patients:
- Pulmonary injuries (pneumothorax and pulmonary contusion).
- Shoulder dislocations (anterior or posterior).
- Brachial plexus injuries and Axillary Artery injury
clavicle fractures are commonly seen in what patients
neonates and children
*generally heal well
*In adults, the force required to fracture the clavicle is greater and healing occurs at a slower rate
Clavicle fractures in adults have a higher risk of complications such as
malunion and non-union
pitfalls of clavicle fx
- visible lump
2. pain w/ carrying a back-pack
Tx of a clavicle fx
- sling or figure 8 strap for 3-4 weeks in children and 4-6 weeks in adults
* Figure 8 not frequently used that much bc it doesn’t do that much–> stabilizing with sling does the same thing
What is the most common type of biceps tendon rupture and what it its tx
rupture of the proximal long head of the biceps and it is usually non-surgical, other than for cosmetic reasons.
distal bicep tendon ruptures are associated with ___ and tx is ___
weakness in supination
treatment is surgical repair depending on co-morbidity factors.
What is the popeye deformity associated with
proximal biceps tendon rupture
Shoulder OA is a gradual, progressive, mechanical, and biochemical breakdown of the ___ and ___ including ___
articular cartilage and other joint tissues, including bone and joint capsule
Risk factors for shoudler osteroarthritis
- age
- genetics
- sex
- weight
- joint infection
- hx of shoulder dislocation
- previous shoulder injury
- certain occupations: heavy construction or overhead sports
Shoulder Xray showing shoulder replacement surgery needs to be done due to OA
- AP
- humerus head becomes flat
- big tear drop osteophyte or bone spur
A “tear drop osteophyte” is associated with
severe OA needing shoulder replacement surgery
Types of shoulder arthroplasties
- total shoulder
- hemi
- reverese total shoulder- LAST RESORT, does not tolerate a lot of stress
