Shoulder, Elbow Flashcards
Reason for shoulder instability?
Shallowness of glenoid fossa of scapula + lack of support of GH joint provided by weak GH Ligs, transverse humeral lig.
Strength mainly depends on rotator cuff
How to diagnose shoulder instability?
Clinically with increased anterior and posterior humeral translation, a sulcus sign, and overall increased external rotation.
Mechanism of shoulder instability?
Microtrauma from overuse = overhead throwing, volleyball, swimmers etc
General lig laxity = a/w connective tissue disorders: Ehlers-Danlos and Marfan’s
What is primary role of rotator cuff?
Stabilize GH joint by compressing humeral head against glenoid
Treatment for shoulder instability?
Non-op = Dynamic Stabilization physical treatment
Op = Capsular shift/stabilization procedure
Signs of shoulder instability in PE?
Sulcus sign
Apprehension/relocation test
Ant / post load and shift test
Neer/Hawkins test
Must have instability in 2 or more planes for MDI
Another name for Traumatic Anterior Shoulder Instability?
Traumatic Unilateral Dislocations with a Bankart lesion requiring Surgery
TUBS!
How do TUBS occur?
Result of anterior force to shoulder while abducted + externally rotated
Commonest injury that comes with TUBS?
Bankart lesion
2nd: Hill-Sachs defect
Avulsion of ant labrum and ant band of IGHL from ant inf glenoid.
What does AMBRII recurrent shoulder instability stand for?
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inf capsular shift
Interval closure
Why are inferior shoulder dislocations rare?
There are no muscles at the bottom, but deltoids hold the muscle up
What is Hill-Sachs defect?
Chondral impact injury in posterohumeral head 2° to contact with glenoid rim.
Present in 80-100% of traumatic dislocations.
Associated injuries of Anterior dislocation?
Bankart, Bony bankart, Hill-Sachs
Rotator cuff tear
Fracture-dislocation: proximal humerus
Axillary nerve (mainly)
Axillary artery injury
Late complications of anterior shoulder dislocation?
Shoulder stiffness
Unreduced dislocation
Anterior instability
How does anterior shoulder dislocation happen?
FOOSH.
Head of humerus displaced anteriorly and glenoid labrum avulses
How does Anterior inferior instability occur??
Fall on backward stretching arm.
Arm for
How does Acromioclavicular injury occur?
Fall on shoulder with arm adducted.
Upward subluxation of clavicle.
Signs of acromioclavicular injury?
AC joint tenderness
Prominent “step” deformity
Scarf test
**
What XR view for Acromioclavicular injury?
Stress view. Pt stands holding 5kg weight on each hand. Diff in distance btw coracoid and inf border of clavicle >50% means AC dislocation
Rockwood classification for AC tear?
Type 3 = both AC and CC ligs torn. Type 3 onwards need surgery.
Presentation of Sternoclavicular injury?
Ant dislocation = Deformity with palpable lump
Post = Impingement on medistinal fractures - dysphagia etc
Pain relieved on ipsilateral head rotation
For ant dislocation, lump increases with arm abduction and elevation.
What can cause winged scapula?
Weak serratus anterior!
Fairly obvious bump/step over AC joint.
What is Tennis Elbow?
AKA Lateral Epicondylitis!
Overuse injury - tendinosis and inflamm of Extensor Carpi Radialis Brevis
What is Golfer’s elbow?
Medial Epicondylitis
Overload at origin of flexor-pronator mass. PT, FCP, FDS, palmaris longus, FCU.
Causes tendinosis + inflamm.
Most common cause of Cubitus valgus?
Chronic non-union of fractured lateral condyle.
Comp: Delayed/tardy ulnar nerve palsy
Most common cause of Cubitus Varus?
Malunion of supracondylar fracture in childhood.
Can cause nerve palsy
Terrible Triad for elbow dislocations?
Posterolateral elbow dislocation
Radial head fracture
Coronoid tip fracture
Common site of clavicle injury? Why?
**Junction btw middle 1/3. **
Bone transits from tube to flat area, lack of muscle attachment, little cancellous bone
Mechanism of clavicle injury?
Fall on shoulder or FOOSH
Conservative Mx for clavicle healing?
Sling immobilization - PT gentle ROM at 2-4 weeks
Strengthening at 6-10 weeks.
Can only be done if :
<2cm shortening+displacement
<1cm displacement of superior shoulder suspensory complex
No neurovascular injury
Who commonly gets proximal humerus fractures?
Osteoporotic, post-menopausal women
What neurovascular injury can come from proximal humerus fracture?
Axillary nerve!
Brachial plexus/artery
Can humeral head have AVN in proximal humerus fracture?
Yes. A/w anatomical neck fractures
Rockwood classificaation for AC joint?
1 = AC lig stretched
2 = Partial rupture of AC ligs
3 = Full rupture of AC + CC ligs
4 = Clavicle displaced post over acromion
5 = Clavicle displaced just under skin
6 = Clavicle underneath coracoid
What is Essex-Lopresti?
Radial head fracture with associated injury to the forearm interosseus membrane and longitudinal instability of DRUJ.
Weight distribution in axial loading of extended elbow?
40% ulnohumeral joint
60% radiohumeral joint
Flexors of elbow?
Biceps
Brachialis
Brachioradialis.
Extensor is triceps
Ligs in radial head fracture?
LCL complex - LUCL, RCL, Annular, accessory lateral collateral
MCL - Ant, post, transverse bundle
LUCL = primary stabilizer to varus and hypersupination stress
Ant bundle of MCL = primary stabilizer to valgus stress
Mason classification for radial head fracture?
1 = Undisplaced or <2mm, no mechanical block to rotation
2 = Displaced >2mm or angulated, possible mechanical block to forearm rotation
3 = Comminuted and displaced, mechanical block to motion
4 = Radial head fracture with associated elbow dislocation
Normal angle of ROM in elbow joint?
Flexion Extension = 150°
Pronation = 85°
Supination = 75°
Principle for distal radius fracture Mx?
Mason 1 = Simple short immobilization with early ROM
Mason 2/3 = ORIF
Mason 3 w comminuted >3 segments = radial head arthroplasty
Terrible triad/Monteggia/Essex Lopresti = arthroplasty
Early ROM impt cuz elbow gets stiff super fast
What is Monteggia fracture?
Proximal 1/3 ulna fracture a/w radial head dislocation
Rare in adults, mostly children
What Lig damaged in Monteggia?
Annular lig
Bado classification for Monteggia?
1 = of prox or mid 1/3 of ulna # with Ant dislocation of radial head
2 = prox or mid 1/3 of ulna # with post dislocation of radial head
3 = Fracture of ulnar metaphysis with lateral dislocation of radial head
4 = Frac of prox or mid 1/3 of ulna + radius with dislocation of radial head in any direction
1 most common in children
2 most common in adults
What is Galeazzi fracture?
Distal 1/3 radial shaft # a/w DRUJ injury
How does Galeazzi occur?
FOOSH with forearm in pronation
OTA classification for Galeazzi?
22-A2.3 = diaphyseal, simple # of radius
A3.3 = diaphyseal, simple # of both bones
B2.3 = wedge # of radius
B3.3 = Wedge # of both bones with DRUJ dislocation
Applicable for both Radius/Ulna #
For Galeazzi means mUST have DRUJ dislocation
Signs of DRUJ injury on XR?
Ulnar styloid #
Widening of joint on AP view
Dorsal or volar displacement on Lat view
Radial shortening of 5mm or more
Complication of Monteggia?
Neurovascular injury = PIN syndrome
Unreduced dislocation
PIN Syndrome = radial nerve, motor only
Complications for Galeazzi?
AIN syndrome - median nerve, motor only
Anatomical landmark for radius fracture to be called DISTAL?
DISTAL 3cm
Neers classification for proximal humerus frac?
One-part [no displacement]
2-part [1 displaced part]
3-parts [2 displaced parts]
4-parts [3 displaced parts]
Predictor of humeral head ischemia in proximal humerus #
Hint: Hertel criteria
<8mm calcar length attached to articular segment
Disrupted medial hinge
Increasing # complexity
Displacement >10mm
Angulation >45°
Humeral head ischemia does not confirm mean subsequent AVN
Blood supply for proximal humerus?
Ant and post humeral circumflex artery.
Post is main blood supply to humeral head.
Ant branch has large anastomosis with other vessels in prox humerus
Complications of humeral shaft frac?
Early = Radial nerve function
Wrist drop, MCP extensor paralysis, profunda brachii artery
What is Holstein Lewis frac?
Spiral frac of distal 1/3 of humeral shaft often a/w neuropraxia of radial nerve
When reduced, radial nerve is impinged in frac site
What ROM affected in humeral shaft fracture?
Depends on site!
STAR!!! Shortening + Translation + Angulation + Rotated
Frac above deltoid insertion = prox fagment adducted by pec major
Frac below deltoid insertion = prox fragment abducted by deltoid
Classification for distal humerus fracture?
A = extra-articular supracondylar
B = Intra-articuar unicondylar, partial articular
C = Intra-articular. Both columns fracture and no part of joint is contiguous with shaft
Complications of distal humerus #?
Early = Neurovascular injury - MN/UN. Check brachial pulse
Late = Elbow stiffness, heterotrophic ossification
when to do total elbow arthroplasty in distal humerus frac?
Communited articular fracs in osteoporotic bone
Inflammatory conditions e.g. RA
What is adhesive capsulitis?
Frozen shoulder
Inflammatory process causes fibroblastic proliferation of joint capsule causing thickening, fibrosis and adherence of capsule to itself and humerus
What is Frozen shoulder a/w
DM
Thyroid disorders (Autoimmune)
Dupuytren’s disease
Atherosclerotic disease
Cervical disc disease
Mechanism of Frozen shoulder injury?
Idiopathic
Post-trauma
Post-surgical
What does frozen shoulder cause?
Functional loss of both passive and active shoulder motion
Acute calcific tendinitis pathophysiology and symptom?
Deposition of calcium crystals in supraspinatus tendon.
Intensely painful but rapidly better
Epidemiology of Rotator cuff tendinitis pathos?
Acute calcific tendinitis [ACT] vs Chronic tendinitis [CT]
ACT = Young adults <40yo
CT = adults 40-60yo
Presentation of chronic tendinitis?
Worse at night, cannot lie on affected side
Treatment of Frozen shoulder?
PT usu enough
NSAIDs + intra-articular steroid injections
Manipulation under anaesthesia [op]
Arthroscopic/open capsular release [op]
