Shoulder/Elbow Flashcards
5 phases of throwing?
Phases of throwing:
1-Wind up
2-Cocking: early (deltoid); late(high torque phase w/ max shoulder ext and elbow valgus w/ peak supra, infra and teres minor activation)
Phase where MUCL shows instability/elbow valgus stress highest (late cocking)***
3-Acceleration: early (triceps); late (pec major, lat, serratus)
4-Deceleration: eccentric of all muscles…HIGHEST torque phase/MOST HARMFUL part of throwing (SLAP, biceps injuries)
5-Follow through: Where body rebalances and stops forward motion
What muscles help provide medial elbow support to prevent valgus instability during pitching?
FDS
FCU
What ligament prevents inferior restraint with arm at 0 degrees or adducted?
SGHL and CHL
What ligament prevents anterior and posterior restraint with arm at 45 degrees or abducted?
MGHL
What ligament prevents posterior restraint with arm at 90 degrees or 90 deg forward flexed, abducted, and IR?
Posterior band of IGHL
tightness leads to internal impingement nd increased shear across superior labrum (SLAP)
What ligament prevents anterior and inferior restraint with arm at 90 degrees and maximally ER/late cocking of throwing?
Anterior band of IGHL
What is a Buford complex?
Absent anterosuperior labrum and cordlike MGHL
1.5% population
Attaching complex will lead to painful and restricted ER (with arm at side**) and elevation **
What is included in rotator interval?
CHL, SGHL, capsule, Long head of biceps
What is major blood supply of humeral head?
Posterior humeral circumflex artery
Benefit of arthroscopic repair for anterior instability vs open?
Preservation of ER***
Spares subscap and much ofanfterior capsule
Hamada classification for rotator cuff arthropathy?
Gr 1: acromiohumeral interval > 6 mm
Gr 2: Interval <5 mm
Gr 3: <5 mm with acetabularization of acromion
Gr 4: GH arthritis
Gr 5: humeral head collapse
Lat transfer performed for?
Who is it good for?
Risks?
Pseudoparesis with ER***
Good for: young laborer
Risk: radial nerve***
Runs along anterior surface of lat, 3 cm medial to humeral head insertion
Posterior branch of axillary nerve
Runs in deep fascia of posterior deltoid
Pec transfer for?
IR deficiency and subscap insufficiency
Upper portion or whole pec transferred near subscap insertion on lesser
Going UNDER conjoined tendon more closely replicates vector forces of subscap**
Risk: Musculocutaneous nerve injury***
Rotator cuff footprint
How wide is Supra insertion?
How far from articular cartilage?
How long AP (supra and infra)?
Medial-lateral width = 14-16 mm (6-8 mm tear = 50% partial thickness tear)
1.6-1.9 mm from cartilage
20 mm in AP diameter
What % of 60 y/o patients will have a rotator cuff tear on MRI?
approx 55%
Treat bursal sided or articular sided rotator cuff tears more aggressively?
Bursal sided (repair these when >3 mm/25% in depth)
Articular sided tears complied and fixed when 50% or 6 mm
Double row cuff repair vs single row?
Dbl row show LOWER retear rate***
Higher ultimate tensile load to failure***
No diff in pain score, functional score, time to healing
Where will RCR fail?
Risk factors for failure
failure to heal, causing pull out from repaired tissue***
Risk factors >65*** (Highest risk factor***) Large tear Muscle atrophy*** DM Smoker Tear medial to glenoid Concomitant AC and/or biceps procedure at time of RCR***
Does PT or guided early RoM improve stiffness at 1 year after RCR?
No
Who does poorly after a lat transfer?
Subscap tear patients*
Women do worse than men*
Ptswith less than 90 deg FF
How long to protect RCR after surgery?
Repaired tendons should be protected from stress for minimum 6 weeks and more likely 8 weeks***
Compared to non workers comp patients that underwent RCR, workers comp patients do better, worse, same functionally and with satisfaction of procedure?
Worse functionally
Lower patient satisfaction
When treating subscap tear, what to do with biceps?
Tenotomy or tenodesis***- better clinical outcomes
What factor has been shown to be increased in patients with subacromial bursitis?
Metalloproteases*** and other inflammatory markers (COX, TNF-alpha, IL1, IL6)
What type of crystals in calcific tendonitis?
Calcium carbonate crystals***
post op rehab after biceps tenodesis?
Avoid active forearm supination with elbow at 90 deg
when to operate on AC joint?
- lateral clavicle displaced through trapezius
- coracoclavicular distance greater than 100% of contralateral side
- normal is 11-13 mm - inferior dislocation of lateral clavicle
Outcomes of type 3 AC separations treated with and without surgery?
Non operative have higher
DASH scores at 6 weeks in 3 months
equal function at 1 year
lower rate of secondary surgery for removal of hardware compared to those treated operatively
nonsurgical LESS LIKELY to develop acromioclavicular arthritis*** ( lack of articular surface contact)
what type of failure will be symptomatic in an acromioclavicular fixation case treated with a modified Weaver Dunn?
Reconstruction does not restore the native stability of the AC joint.
Persistent horizontal/ anterior to posterior instability may cause persistent symptoms***
what views most accurate for the AC joint radiographically?
Zanca view
what causes distal clavicle osteolysis?
Repetitive stress and microfracture in the distal clavicle which leads to osteopenia
mostly males in their 20s. Commonly seen in weightlifters.
How test for laxity of the rotator interval?
Pt shows:
Increased external rotation with the arm fully adducted and at 90° abduction***
tightening rotator interval will most significantly decreased range of motion in external rotation with the arm ADDUCTED**
what defined generalized ligamentous laxity?
Beighton’s criteria greater than 4/9
able touch palm still floor while bending at waist - 1 point
Genu recurvatum - 2 point
elbow hyperextension -2 points
MCP hyperextension - 2 point
Thumb abduction to the ipsilateral forearm - 2 points
MRI finding of multi directional instability?
Capacious capsule without presence of tears
Side effects of radiofrequency or laser thermal capsularrhaphy?
glenohumeral chondrolysis***
Recurrent instability***
what size defect defines critical bone loss in the bony Bankart lesion?
20-25%
newer studies say may be as low as 13.5%
what % of traumatic dislocations and traumatic subluxations cause a Hill-Sachs defect?
Dislocations: 80%
Traumatic subluxations: 25%