Shoulder/Arm Flashcards
Lateral vs medial winging?
Trapezius - lateral winging (spinal accessory n)
Serratus anterior - medial winging (long thoracic n)
Clavicle fracture groups?
Group 1 - Middle 1/3 (most common, 80%)
Group 2 - Distal 1/3
Type 1 - lateral to CC ligaments
Type 2a - medial to CC ligaments
Type 2b - between CC ligaments (conoid torn, trapezoid intact)
Type 3 - fracture into into AC joint
Group 3 - Proximal 1/3
Associated injury with scapula fracture?
(85% have associated injuries) - Rib fx #1, pulmonary contusion, pneumothorax, brachial plexus injury
Ideberg classification
Glenoid fracture:
Type I: anterior avulsion fracture
Type II: transverse/oblique fx through glenoid, exit inferiorly
Type III: oblique fracture through glenoid, exits superiorly
Type IV: transverse f exits through scapular body
Type V: type II + type IV
Rockwood classification
AC separation
I: Sprain
II: AC tear, CC intact
III: AC+CC tears
Hill-Sachs lesion
Posterolateral humeral head compression fracture often secondary to multiple anterior shoulder dislocations
Glenohumeral dislocation, most common and associations?
Anterior more common (>90%) >90% recurrence if
Neer classifications
Proximal humerus fracture
Based on number of free fragments (head, greater/lesser tuberosity, shaft), must be >1cm displaced
Buford complex?
Thickened MGHL and absent anterior/superior labrum
Significance of SGHL?
resists inferior translation and ER in shoulder abduction
Significance of MGHL?
resists AP translation in 45° of abduction
Significance of IGHL (and components)
MOST IMPORTANT LIGAMENT
Anterior band of IGHL - resists anterior and infection translation in abduction and ER
Posterior band of IGHL - resists posterior translation in IR and 90o flexion
Superior transverse scapular related nerve/artery?
Suprascapular nerve travels UNDER it, suprascapular artery travels OVER it
Impingement sign test
Impingement: forward flexion more than 90°, pain=positive
O’brien’s (active compression)
O’Brien’s: FF 90°, adduct 10°, resist FF in pronation then supination. More pain with pronation = SLAP tear (or AC)
Apprehension test (shoulder)
Apprehension: pain or apprehension on abduction and ER = anterior instability
Cross body adduction
Cross body adduction: adduct arm across body. Pain at AC joint = AC joint path
Proximal humerus insertions
PLT medial to lateral
Pec major, lat dorsi, teres major
Quadrangular space, triangular space, triangular interval. Borders and contents
Quadrangular space: Humerus, teres major, teres minor, long head of triceps. Transmits Posterior circumflex humeral artery and axillary nerve
Triangular space: Teres major and minor, long head of triceps. Transmits circumflex scapular artery
Triangular interval: long and lateral heads, teres major. Transmits radial nerve and profunda brachii (deep artery of arm)
Muscle at risk from anterior approach to shoulder?
Subscapularis
Which muscle protects what nerve in posterior approach to shoulder?
Teres major protects radial nerve
Draw the brachial plexus
do it
Dorsal scapular nerve runs through which muscle
middle scalene
Long thoracic nerve travels on which muscle
serratus anterior
Which muscles does brachial plexus travel between
between anterior and middle scalene
What nerve is at risk in lateral shoulder approach
Axillary nerve
What runs in the deltopectoral groove?
Cephalic vein
Subdivision of brachial plexus?
Roots Trunks Divisions Cords Branches
Branches off of subclavian
VITC,D Part 1) Vertebral a Internal thoracic a Thyrocervical a (Inferior thyroid a., transverse cervical a., suprascapular a.) Part 2) Costocervical a Dorsal scapular a
When does the subclavian change name
After 1st rib, becomes the Axillary artery
Branches of axillary artery
Sixties Teens Love Sex And Pot
1) Superior thoracic
2) Thoracoacromial (Cadavers are dead people = clavicular, acromial, deltoid, pectoral)
Lateral thoracic
3) Subscapular - circumflex scapular, thoracodorsal
Anterior circumflex humeral (main supply to humeral head)
posterior circumflex humeral
Artery at risk in subacromial decompression
Acromial branch of the thoracoacromial
When does axillary artery name change?
Brachial at the lower border of teres major
Defining characteristic of adhesive capsulitis?
decreased active AND passive ROM
Bankart lesion?
Anterior inferior labral detachment from glenoid
Glenohumeral instability, two types
TUBS
trauma, unilateral, Bankart lesion, surgery
AMBRI
atraumatic, multidirectional, bilateral, rehab, inferior capsular shift helpful.
SLAP lesion
Superior labrum (biceps anchor) from anterior to posterior
Sprengel’s deformity
Small scapula, omovertebral bone connects c-spine to scapula. Associated with Klippel-Feil syndrome, scoliosis, kidney disease
Anterior (deltopectoral) shoulder approach internervous planes dangers protect nerve with? Complications
IN planes: Deltoid, pectoralis major
dangers: MC nerve, (retraction of conjoined tendon), cephalic vein, axillary nerve
protect axillary nerve with adduction and ER
Subscapularis rupture
6 portals for shoulder arthroscopy + dangers
Posterior - posterior capsule/labrum Anterior superior - CA ligament/artery Anterior inferior - MC nerve Lateral - axillary nerve Wilmington - safe Neviaser (supraspinatus) - Rotator cuff
Tennis vs golfers elbow
Tennis lateral, golf medial epicondyle
What runs in spiral groove?
Radial n
Holstein-Lewis fracture? Nerve entrapped?
Distal 1/3 humerus fracture, radial n
Supracondylar process ligament entrapping nerve
Ligament of Struthers, entrapping Median n
Most susceptible part of radial head + why?
Anterolateral portion of radial head, less subchondral bone
Humerus shaft fracture?
Descriptive
Distal humerus fracture?
Descriptive (uni/bicondylar, T/y/lambda)
Gartland classification
Extension type supracondylar humerus fracture (Posterior displacement, common in peds)
I: nondispaced
II: partially displaced (post. ctx intact)
III: displaced (no ctx intact)
Colton classification
Olecranon fracture
I: nondisplaced (2mm) + description (avulsed, transvers/oblique, comminuted, displaced)
II: Displaced: avulsion, transverse/oblique, comminuted, displaced fx-dx
Mason classification
Radial head fx
I: nondisplaced (
Risk with olecranon fracture?
ulnar nerve injury
Essex-Lopresti fracture?
Comminuted radial head with dislocation of distal RU joint, proximal migration of radius, and tear of IO membrane.
Terrible triad of elbow
Elbow dislocation, radial head fx, coronoid fx
Most common elbow dislocation?
posterolateral
Nursemaid’s elbow
Radial head subluxation from annular ligament
Bundles of medial ulnar collateral ligament, most important?
Anterior (most important against valgus stress)
posterior, transverse
What compresses ulnar n in cubital tunnel?
Arcuate (Osbourne’s) ligament
Sail sign?
displaced fat pads seen on XR when fracture causes hematoma
Ligament of Struthers can compress
Median nerve proximally
Arcade of Struthers can comress
Ulnar nerve proximal to cubital tunnel
Leash of Henry can compress
radial n/PIN
C5, C6, C7 reflexes?
C5 - biceps
C6 - brachioradialis
C7 - triceps
Tennis elbow test
TET: make fist, pronate, extend wrist and fingers against resistance. pain @ lateral condyle = positive
Conjoined tendon components (on coracoid process)
Short head biceps, coracobrachialis, pec minor
Course of MC nerve in arm
Pierces coracobrachialis, then travels between biceps and brachilais muscles.
Course of radial n in arm
Starts medial, spirals posteriorly, and laterally around the humerus in spiral groove and emerges between brachialis and brachioradialis.
Course of ulnar n in arm
In medial arm from anterior to posterior compartment across the IM septum into cubital tunnel
course of median n in arm
In anteromedial arm, lateral to brachial artery but crosses to become medial.
Course of brachial artery in arm
runs with median nerve, then crosses under it to become more midline in distal arm.
Innervation of brachialis
Medial is MC nerve, lateral is radial n
Where are the 4 places the ulnar nerve can get trapped
IM septum
Arcade of Struthers
Cubital tunnel
FCU fascia
Osteochondritis dissecans of elbow, XR findings?
vascular insufficiency to capitellum. Lucency of capitellum
Humerus anterior approach. IN plane, dangers
Proximal planes: deltoid, pec major
Distal planes: brachialis (radial n lateral and MC nerve medial)
Dangers: proximal - axillary n, humeral circumflex artery
Distal: radial n, MC n
Kocher approach to elbow
Lateral
IN planes: anconeus, ECU
Dangers: PIN, radial n
Keep arm pronated
Posterior approach to elbow
No IN plane, olecranon is osteotomizes.
Dangers ulnar n.
Bryan/Morrey approach to elbow
Posterior approach. Same as other posterior approach, but leave olecranon, triceps is partially reflected.
Dangers: ulnar n.
Elbow arthroscopy portals (5) - dangers
Proximal anteromedial - ulnar nerve, MAC
Proximal anterolateral - radial nerve
Posterocentral - safe (thru tendon)
Posterolateral - med and post antebrachial cutaneous n
Direct lateral - posterior antebrachial cutaneous n
Hawkins test
Hawkins: ff shoulder 90° then IR pain=positive impingement
Empty can test
Empty can: pronate arm, resist FF weakness/pain=SS tear or RC tear
Drop arm test
Drop arm: FF shoulder 90o, hold. drop=SS tear
ER lag sign
ER lag sign: ER shoulder, patient holds. weakness = IS tear
Horn blower’s test
Horn blower’s: ER shoulder in slight abduction. weakness = IS tear
Lift off/lag/belly press:
Lift off/lag/belly press: lift hand off back, press on belly. weakness = subscap tear
Crank test
Crank: abduct, axial load, rotate. pain = SLAP
Speed’s test
Speed’s: resisted FF of shoulder, pain = biceps lesion
Yergason’s test
Yergason’s: elbow 90o, resist supination and ER, feel biciptal groove. Pain = biceps tendinits
Relocation (shoulder)
Relocation: abduct and ER with posterior force to arm. Relief from apprehension = anterior instability
Load and shift
Load and shift: axial load with AP translation. increased translation = anterior or posterior instability
Jerk test
Jerk: supine, adduct, FF90o, push posterior. pain/apprehension/translation = posterior instability
Sulcus test
Sulcus: pull down on adducted arm. Sulcus under lateral acromion = inferior instability
Scapular winging
Scapular winging: Push against wall, winging = LTN/serratus anterior weakness, or trap for lateral winging
Adson’s test
Adson’s: Palpate pulse, rotate neck. Numbness/tingling suggests thoracic outlet syndrome (TOS)
Wright’s test
Wright’s: Extend arm, rotate neck away, Numbness/tingling suggests thoracic outlet syndrome (TOS)
Spurling’s test
Spurling’s: lateral flex/axillary compress neck. symptoms = cervical neck pathology
Golfer’s elbow test
GET: supinate arm, extend wrist and elbow. pain @ medial epicondyle = positive
Ligament instability
Ligament instability: 25° flexion, apply varus/valgus stress. Pain or laxity = positive
Pivot shift shoulder
Pivot shift: supine, extend elbow, flex shoulder above head, supinate, axial load, valgus and flex elbow. Apprehension, palpable subluxation of the radial head or skin dimpling = positive.
Tinel’s arm
Tinel’s: tap in ulnar groove. Numbness/tingling=positive
Elbow flexion: maximal elbow flexion for 3 mins. Tingling = positive
Pinch grip
Pinch grip: pinch thumb and index. Pinching pads = AIN pathology.
