The Shoulder

Question 1

What is the normal scapulohumeral rhythm?

Answer 1

2:1 humeral to scapular movement normally

Question 2

What are the normal strength ratios of the shoulder?

Answer 2

IR:ER - 3 to 2 (IR is 50% stronger)
Add : Abd - 2 to 1 (adduction is 100% stronger)
Ext to flex: 5 to 4 (ext is 25% stronger than flex)

Question 3

Which ligament limits ER with arm at the side and is usually contracted in shoulders with adhesive capsulitis?

Answer 3

Coracohumeral ligament (inserts into RC interval). Usually has to be released to regain full ER.

Question 4

What is the RC interval?

Answer 4

Described by Neer as the capsular tissue interval between suscapularis and supraspinatus tendons. It is composed of parts of the supraspinatus and subscap tendons, the coracohumeral ligament, and the superior glenohumeral ligament. All of these structures contribute to stability by limiting inferior translation and ER when adducted, post translation when the arm is flexed

Question 5

What are the 4 parts of the proximal humerus?

Answer 5

shaft, greater tuberosity, lesser tuberosity, articular or head segment. These corresponds to four ossification centers. The surgical neck is below the tuberosities, the anatomical neck is above. These 4 sections are common sites of fracture and are the basis of Neer’s classification of prox humerus fractures.

Question 6

Describe the layers of the rotator cuff.

Answer 6

The rotator cuff has 5 layers at its superior portion at greater tubercle insertions.Variation in tissue properties/loads among these layers may contribute to RC tears.Basically layer 1 and 4 are coracohumeral ligaments, with layer 2 being the actual RC tendon and 3 being random orientation.fasicles. Layer 5 is the capsule itself.

Question 7

Describe the anatomy of the supraspinatus tendon and its clinical significance.

Answer 7

Supraspinatus has 2 muscle bellies (ant and post). The anterior belly is larger and pulls through a smaller tendon area, meaning increase stress compared to posterior tendon. This is important during surgical repairs.

Question 8

What does the long head of the biceps do?

Answer 8

Opinions vary. May contribute to anterior stability and help depress humeral head in the presence of large RC tear. Elbow flexion strength can dec by up to 30% and supination/abd up to 20% if a tear occurs due to loss of stabilizing function.

Question 9

What is the labral origin of the bicep anchor?

Answer 9

40-60% of the origin is from the supraglenoid tubercle, while the remaining fibers originate from the glenoid labrum in various patterns.

Question 10

What is the quadrangular space?

Answer 10

Antomic interval formed by the humeral shaft laterally, the long head of the triceps medially, the teres minor superiorly, and the teres major inferiorly. The axillary nerve and posterior circumflex humeral artery pass through here.

Question 11

What is the triangular space?

Answer 11

An anatomic interval medial to the quadrangular space. Borders are formed by the long head of the triceps laterally, the teres minor superiorly, and the teres major inferiorly. The circumflex scapular artery (branch of scapular artery) passes through here.

Question 12

How is the GHJ stability maintained?

Answer 12

Through both static and dynamic stabilizers. Statis structures include the capsule and ligaments and are normally lax during mid range, dec movement at extreme ranges. Dynamic is primarily the deltoid and RC and are more active at mid range.

Question 13

What structure is the most important static restraint to anteiorr humeral translation in the 90-degree abd/ER position?

Answer 13

Anterior band of inferior glenohumeral ligament. This is the position most traumatic shoulder dislocations occur. The middle glenohumeral ligament is the restraint at mid range, while the superior ligament prevents excessive ER and inf translation with the arm by the side.

Question 14

What is a Bankart lesion?

Answer 14

Detachment of the anchoring point of the anterior band of the inferior glenohumeral ligament and middle glenohumeral ligament from the glenoid rim (also the labrum) This is a result of a truamatic anterior dislocation. This is the opposite of the HAGL lesion. This can be treated by suturing the ligament and the labrum back to the glenoid.

Question 15

What is a HAGL lesion?

Answer 15

Uncommon. Avulsion of the humeral attachement of the glenohumeral ligament after dislocation. Opposite of Bankart lesion.

Question 16

What is a Hill-Sachs lesion?

Answer 16

An impression fracture of the posterolateral margin of the humeral head caused by impaction on the rim of the glenoid during anterior shoulder dislocation.

Question 17

What is the function of the clavicle?

Answer 17

Acts as a strut to inc biomechanical efficiency of axiohumeral muscles.

Question 18

Subclavius.

Answer 18

O: first rib
I: inferior middle third of clavicle
N: Nerve to Subclavius (C5, C6)
A: stabilizes sternoclavicular joint.

Question 19

What is the primary areterial supply to humeral head?

Answer 19

Anterior circumflex artery. It ascends via the bicipital groove along with the LHB tendon.

Question 20

Describe the course of the suprascapular nerve/

Answer 20

Arises from the superior trunk of the brachial plexus (C5, C6). Courses posteriorly to the suprascapular notch along with the artery. The nerve travels through the suprascapular notch, under the transverse scapular ligament, while the artery goes above. Next it passes through the spinoglenoid notch below the spinoglenoid ligament.

Question 21

What neurovascular structure is at greates risk during anterior shoulder surgery?

Answer 21

Axillary nerve. It travels posteriorly from the post cord of the brachial plexus to innervate the deltoid and teres minor. It, along with the posterior circumflex humeral artery, passes below the inferior border of the subscap and travels along the inferior genohumeral joint capsule.

Question 22

Which nerve lies superficial in the posterior cervical triangle and is susceptible to injury?

Answer 22

Spinal Accessory nerve (CN XI), just below cervial fascia. The post cervical triangle is borderd by the SCM anteriorly, the trap posteriorly, and the clavicle inferioly. May be injured during cervical lymp node biopsy. Will result in drooping of the shoulder, pain, and weakness in arm elevation.

Question 23

Which nerve causes classical medial scapular winging?

Answer 23

Long Thoracic nerve

Question 24

Describe the course of the musculocutaneous nerve.

Answer 24

Terminal branch of the lateral cord of the brachial plexus (C5,6,7). Penetrates coracobrachiallis and sends off motor branches. Travels between brachialis and biceps brachii, inervating both. Sensry branches emerge between the brachialis and brachioradialis muscles and travels into the forearm as the lateral antebrachial cutaneous nerve.

Question 25

Is the acromial attachment of the coracoacromial ligament and anterior deltoid preserved during arthroscopic acromioplasty?

Answer 25

No, typically it is released. The overlying deltoid insertion remains attached by a bridge of tissue composed of periosteum and deltoid tendon.

Question 26

Describe the anatomy of the pec major tendon and associated nerves.

Answer 26

The pec major insertion is aprpox 2 inches wide with a broad undersurface and small anterior surface. The sternal head spirals posterior, the clavicular anterior. The medial pec nerve is inferior to the lat pec nerve insertion. The lateral pectoral nerve passes medial to the pec minor befor entering the pec major, whereas the medial pec nerve passes through or lateral to pec minor befor entering pec major.

Question 27

What are the main stabilizers of the AC joint?

Answer 27

The AC ligament and joint capsule are primary constraints for posterior displacement and rotation. Conoid ligament constrains anterior/superior rotation and displacement. The trapezoid ligament constrians vertical and horizontal displacement.

Question 28

What is the articular version of the proximal humerus?

Answer 28

Typically 30 degrees of retroversion.

Question 29

What is the normal version/tilt of the glenoid?

Answer 29

Approx 8 degrees of retroversion relative to the scapula. Relative to the body, it is oriented anteriorly. Excessive retroversion may contribute to posterior instability, while upward facing glenoids may inc RC disease risk.

Question 30

What are the three morphologic types of the acromion?

Answer 30

``` Bigliani classified 3 types. Type 1 - Acromion is flat (17%) Type II - Acromion is curved (43%) Type III Acromion is hooked down (40%) Out of patients c RC tears, 70% have type III, 27% have type II, and 3% have type I. Types II and III impinge on RC tendons ```

Question 31

Are types II and III acromia aquired or developmental?

Answer 31

Possibly aquiared. The hooks lie with in the coracoacromial ligament and may be traction spurs due to the humeral head pushing up on the arch.

Question 32

Describe Neer's RC pathology classification.

Answer 32

Stage 1: edema and hemorrhage; pt is less than 25 yo and have pain that resolves with rest. Reversible. Conservative Tx. Stage 2: fibrosis and tendinitis. Patients typically 25-40 and have recurrent pain. Possibly consider SAD if conservative Tx fails. Stage 3- Bone spur and tendon rupture. Pts typically older than 40 with history of progressive disability. RCR advised. Stage 4- Pt typically older than 60. cuff tear arthropathy. RCR, TSA recommended

Question 33

What is the coracoacromial arch and why is it important?

Answer 33

Formed by the coracoacromial ligament, it is the roof of the shoulder. Protects the subacromial bursa and RC tendons. Restricts excessive superior migration. With elevation and IR the greater tuberosity and RC tendons may compress against this.

Question 34

What is a partial-thickness RC tear?

Answer 34

Naturally degenerates with increasing age, especially in 40s+. Degeneration begins deep within the tissue near the undersurface attachment of the tuberosity. Tears may also occur on the bursal side of the cuff near the insertion.

Question 35

Do partial-thickness tears heal or progress to full-thickness tears?

Answer 35

Usually. Typically occurs because ruptured fibers can no longer sustain load so surrounding fibers have more stress. Disruption also disrupts local blood supply within the tendon. Disrupted fibers are exposed to joint fluid which has a lytic effect. If the tendon does heal, the scar tissue does not have the same tensile strength.

Question 36

What is RC arthropathy?

Answer 36

With massive tearing, tendons slide off the humeral head. They then act as elevators and promote superior humeral head translation, causing excessive wear and degeneration. May lead to TSA or hemi-arthroplasty if it becomes severe enough.

Question 37

When are acromioplasty and subacromial decompression required?

Answer 37

Typical patient is between 25-40 years old and has recurrent pain and failed conservative treatment. Some surgeons advocate retaining the coracoacromial ligament to preserve teh arch/superior migration.

Question 38

What is the Mumford procedure?

Answer 38

An excision of the distal 2cm of the clavicle. Often used to allow greater RC decompression or to dec pain from AC dislocation.Distal stability of the scapula is maintained through the intact costoclavicular ligaments (conoid and trapezoid) since the AC joint no longer exists.

Question 39

What are some primary RC exercises?

Answer 39

Supraspinatus: can be worked with prone Y's Teres minor: Prone ext with ER (T's with thumbs up) Subscapularis: IR can be performed any way.

Question 40

What RC exercises result in the greatest EMG activity?

Answer 40

Sidelying ER results in greatest EMG activity of infraspinatus and Teres minor. Suprasinatus is greatest in prone Y's with thumbs up, but this is an advanced exercise.

Question 41

What is the difference between primary and secondary RC impingement?

Answer 41

Primary (structural) is a mechanical impingement of RC below coracoacromial arch and results from overcrowding. Secondary is due to space being decreased because of instability/poor control

Question 42

What is posterior (internal) impingement?

Answer 42

Pinching of the infraspinatus adn supraspinatus between teh posterior superior aspect of genoid and the upper limb, when in the cocked position (Throwing position). Occurs on the undersurface rather than the bursal side. May be associated c ant instability.

Question 43

What classification is used to describe the extent or size of RC tears?

Answer 43

AAOS: small tear is <5 | Stage 3 is 5 cm +

Question 44

Do full-thickness RC tears heal?

Answer 44

No. Primary healing is unlikely, but nonoperative management may result in functional and pain improvement.

Question 45

Describe typical protocols for RCR Tx.

Answer 45

The typical open RCR is followed by a short period of immobiliation (1-6 weeks depending on the size of the tear). Early PROM exercises(flex,abd, ER) including pendulum and pulleys begin within the first few post-op days. Surrounding joint ROM is inorporated. Submax isometrics may begin at 3-4 weeks. (perform in scapular plain if possible). Rythmic stabilization is incorporated. Isotonic exercises typically begin 4-6 weeks post op. Full ROM should be restored by 8-10 weeks.

Question 46

Describe the Neer impingement test.

Answer 46

Place one hand posteriorly over scapula and grasp elbow. Keeping scapula stabilized, pasively flex shoulder maximally. Shoulder pain and aprehension is a + sign, indicating supraspinatus or biceps tendon involvement.(greater tubercle hits acromion) (Sn: 89%, Sp: 25%)

Question 47

Describe the Hawkins-Kennedy Impingement Test.

Answer 47

Flex shoulder to 90 degrees and then IR the shoulder. Pain and aprehension is a +sign. (pushes supraspinatus tendon against the anterior coracoacromial arch. (Sn: 92%, Sp: 25%)

Question 48

Describe the Reverse Impingement Sign.

Answer 48

In the presence of painful arc or pain with ER, patient lies supine. Push the humeral head inferiorly while abductiong, ER shoulder. + for mechanical impingement if pain is decreased or abolished.

Question 49

Describe the cross-over impingement test.

Answer 49

Place one hand over the posterior aspect of the scapula and grasp patient's elbow. Maximally adduct arm horizontally. Superior shoulder pain is AC joint pathology, anterior shoulder pain may be subscap, supraspinatus, or LHB. Posterior shoulder pain may be infraspinatus, teres minor, post joint capsule.(Sn: 82%, sp: 28%)

Question 50

Describe the supraspinatus or empty can test performed.

Answer 50

Stand with both shoulders abducted to 90* in the scapular plane and IR so that the thumbs point down. Apply resistance against abduction. Pain or weakness indicates tear of the supraspinatus or injury to the suprascapular nerve.

Question 51

Describe the drop arm test.

Answer 51

Passively plae involved shoulder in 90* of abduction and ask patient to slowly lower arm. A + sign is inability to slowly lower the arm or reproduction of pain, indicating RC tear. (Sn: 8%, Sp: 97%)

Question 52

Describe the lift-off sign.

Answer 52

Stand with the back of the hand against the back pocket and lift away from the back. Inability to perform this may indicate subscap tear. May also reveal scapular instability. (Sn: 62%, Sp: 100%)

Question 53

Describe the drop sign.

Answer 53

Place patient's arm in 90* of elbow flexion, 90* of abduction, and full ER (throwing position). Release the arm. A drop or lag indicates infraspinatus insufficiency. (Sn: 20%, Sp: 100%)

Question 54

Describe lag signs of the shoulder.

Answer 54

ER lag sign: place arm in 90* of elbow flex, 20* of shoulder elevation in scapular plane and full ER. Let go of wrist support while supporting elbow. + for supraspinatus or infraspinatus pathology if patient cannot maintain position. Lag is recorded to the nearst 5*. (Sn: 70%, Sp: 100%) IR lag sign: Basically the lift off sign, but examiner passively lifts hand and supports elbow. When the wrist is released, a +sign is a drop Lag is recorded to the nearest 5*. (Sn: 97%, Sp: 96%)

Question 55

What are 3 of the most sensitive tests for RC pathology?

Answer 55

IR lag test (97%), Hawkin's Kennedy Impingement Test (92%), Neer Impingement Test (89%)

Question 56

What are 3 of the most specific tests for RC patholgoy?

Answer 56

IR lag test, ER lag test, lift off sign (all 100%). Drop arm test is 97%

Question 57

How accurate is a clinical exam of the shoulder in predicting RC pathology?

Answer 57

Sensitivity is approx 91%, specificity is 75%. Data that assists is age of the patient >40, previous trauma.

Question 58

What clinical tests are most predictive for RC tear?

Answer 58

According to Murrel and Walton, 3 tests in a cluster are highly predictive: supraspinatus weakness, ER weakness, and impingement sign. If all are positive (or if 2 are positive and the patient is 60 or older), the individual had a 98% chance of having a tear. A positive drop arm test is just as good by itself. If none are positive, less than a 5% chance of a tear.

Question 59

What is the most accuratte immagin gstudy for diagnosing RC tears?

Answer 59

Ultrasonography (Sn: 98%, Sp: 91%). Comparable to surgical findings. MRIs are around 80% sensitive and 80-90% specific.

Question 60

What are the exptected outcomes of RCR at 1 and 5 years?

Answer 60

Facorable outcomes are acheived in 75-90% of patients according to research

Question 61

What is the best conservative PT intervention for shoulder (RC) pain?

Answer 61

Evidence shows exercise is effective short term and long term, but that exercise and nonthrust mobilization (post/inf glides) are more effective than exercise alone.

Question 62

What is the most common nerve injury after anterior shoulder dislocation?

Answer 62

Axillary nerve (30%), most commonly traction neurapraxia

Question 63

Why is posterior shoulder dislocation more likely than anterior following electric shock or convulsive seizures?

Answer 63

Because the adductors, IR, and extesnors are stronger and cause this pull.

Question 64

What does the acronym TUBS mean?

Answer 64

Related to shoulder dislocation T-traumatic onset U - unidirectiona; (anterior) B - Bankart lesion S- Surgery (success rate with nonoperative Tx iss less than 20%)

Question 65

What is meant by the acronym AMBRI?

Answer 65

Related to shoulder dislocation ``` A- atraumatic onset M- multidirectional B - bilateral R - rehab is successful in 80% I - inferior capsular shift is the Tx of choice if conservative Tx fails. ```

Question 66

What is meant by the acronym ALPSA?

Answer 66

Anterior Labroligamentous Periosteal Sleeve Avulsion. Often accompanies an anterior dislocation and is characterized by the labrum and periosteal sleeve of the anterior glenoid being avulsed and displaced medially. This is a variant of a Bankhart lesion.

Question 67

What is meant by the acronym HAGL?

Answer 67

Humeral avulsion of the glenohumeral ligament, usually caused by a traumatic dislocation into hyperabduction

Question 68

Describe the load-shift test.

Answer 68

Allows evaluation of glenohumeral translation. Compression is applied to the humeral head and anterior and posterior forces are applied. The direction and degree of translation is recorded. (Sn: 83%, Sp: 100% under anesthesia)

Question 69

Describe the anterior release test.

Answer 69

Patient is supine with arm in throwing position (90 abd, 90 ER), also known as the apprehension position. A posterior directed force is applied to the humeral head and then released. If apprehension is experienced, the test is positive. (Sn: 92%, Sp: 89%)

Question 70

How is glenohumeral joint laxity graded?

Answer 70

Ant translation up to 25% is considered normal. Grade 1: humeral head moves to the edge of glenoid rim (up to 50% translation) Grade 2: HH moves over edge of glenoid rim but reduces with pressure. Clinically this is subluxation. (more than 50% translation) Grade 3: dislocation

Question 71

Describe the Hill-Sachs lesion and reverse Hill-Sachs:

Answer 71

Hill-Sachs lesion is a compression fracture of posterior lateral humeral head due to impact of humeral head on anterior inferior glenoid rim during anterior dislocation. A reverse occurs with posterior dislocation (anterior medial humeral head)

Question 72

Are dislocations recurrent?

Answer 72

Patients under 20 have a recurrence rate up to 20%. If you dislocate more than once in young patients, the chance of frequent recurrence goes to almost 100%.

Question 73

What is the PT Tx for anterior dislocation?

Answer 73

ROM exercises (avoid abduction and ER), strengthening of scapular and shoulder muscles (scapula first)

Question 74

What is a SLAP lesion?

Answer 74

Superior labral anterior to posterior lesion, usually resulting from a downward force on a supinated outstretched UE or falling on the lateral shoulder. Usually leads to popping and sliding.

Question 75

What are the special tests to evaluate SLAP lesions?

Answer 75

O'Brien test: arm is flexed to 90* with full IR and horizontal adduction.The patient tries to resist a forward force at the wrist. Pain indicates a positive test SLAP test: Arm is extended, supinated, and abducted to 90 degrees. Push down at the wrist while using thumb of opposite hand to shift humeral head in opposite direction. Load-shift test: Thumb is used to push the humeral head superiorly and anteriorly while the arm is in the throwing position

Question 76

What is the difference between primary and secondary adhesive capsulitis?

Answer 76

Primary is insidious onset, whereas after trauma or an inciting event it is called secondary.

Question 77

Describe the natural resolution of adhesive capsulitis.

Answer 77

Early painful stage is characterized by diffuse pain and restricted movement due to pain (freezing). Last 2-9 months. Stiffening stage is progressive loss of ROM and function (lasts 4-12 months) Recovery stage lasts 5-24 months and is gradual increases in ROM and dec pain. Time to resolution is usually 1-3 years.

Question 78

What PT Txs are beneficial for adhesive capsulitis?

Answer 78

Home stretching is helpful (90% had positive outcomes). Exercise is more helpful than modalities, NSAIDs, or steroids. Mobilization is helpful.

Question 79

Describe the typical TSA patient and why do patients get them?

Answer 79

Usually 55-70 years old. OA, AVN, RC arthropathy with subsequent dysfunction are indications.

Question 80

What is the difference between the types of TSAs?

Answer 80

Constrained TSA: uses a ball and socket design; reduces total humeral motion. Unconstrained TSA: closest to normal GHJ anatomy Reverse: places ball component on glenoid side and socket on humeral sign (advantageous for patients with deficient cuff because it places deltoid in better position.

Question 81

What is the difference between hemiarthroplasty and TSA?

Answer 81

Hemi is a replacement of the humeral component and is indicated when glenoid is intact. Surgery of choice if physical demands are high after surgery. TSA appears to be better in most cases

Question 82

What are post-op goals of TSA?

Answer 82

Primary is to relieve pain. Secondary is to restore function/ROM. Active elevation typically increases 50 degrees while ER improves 30 degrees. Non impact sports such as swimming and bowling are possible following surgery.

Question 83

Is all passive elevation the same?

Answer 83

No. PROM or AAROM in supine position results in less EMG activity than passive elevation in sitting or standing with pulleys or canes.

Question 84

What is the Neer-phased rehab program?

Answer 84

Neer describes 3 phases of rehab following TSA or RCRs: Phase I: PROM exercises and AAROM such as pulleys, canes, and tabletops. Phase II: active motions Phase III: restrictive exercises

Question 85

What are standard precautions following TSA?

Answer 85

Self-transfers and ambulation with crutches should be avoided until adequate strength is regained (approx 6 months). Patients may need to progress slowly.

Question 86

What are the typical mechanisms of ACJ injuries?

Answer 86

direct force to the tip of the shoulder with the arm adducted (acromion is driven inferiorly). A secondary mechanism is falling on an outstretched hand, causing the humeral head to hit the acromion. AKA shoulder separation

Question 87

What are the ligaments of the shoulder AC joint?

Answer 87

3 major: conoid, trapezoid, and AC ligaments. (conoid and trapezoid ligaments are referred to as the coracoclavicular ligament). The AC ligaments (superior and inferior) control horizontal movement. Vertical stability is controlled by the coracoclavicular ligament, with the conoid lying medially and trapezoid lying laterally

Question 88

Describe the acute presentation of AC injury.

Answer 88

The patient typically cradles the involved arm. AC joints are classified as type I-VI (unlike other ligaments because it is multiple ligaments). Type I: sprain of AC ligaments (mild to mod pain, pain free ROM) Type II: complete disruption of AC ligaments, sprain of CC (Mod to severe pain at both AC joint and CC interspace, limited function Type III: complete disruption of AC and CC ligaments (high-riding clavicle, exquisite pain) Types IV-VI: extreme drooping of involved UE, severe pain. requires surgery

Question 89

Describe treatment of AC injuries.

Answer 89

Type I: ice, activity as tolerated. Possible use of donut under pads. It's important to use a donut pad on both sides for normal shoulder pad use Type II: sling as needed, ice, ROM as tolerated (passive first to minimize activation of deltoid and trap) strengthening exercises, return to activity 2-3 weeks after injury Type III: Most is non-op. Tx is much like second degree injury but with greater reliance on immobilizing support. A residual step deformity remains. Long term consequences are a possible step deformity that has no symptomatic consequence.

Question 90

What is the typical mechanism of SC injury?

Answer 90

Relatively rare, but usually sustained via indirect contact such as lying on your side and being forced to roll over the shoulder. Also a direct force to the clavicle

Question 91

What ligaments support and control the SC joint?

Answer 91

The costoclavicular ligament, the interclavicular ligament

Question 92

What muscular force couples act on the scapula during arm elevation?

Answer 92

Upper rotation: Upper trap, serratus anterior, lower traps

Question 93

What is SICK scapula syndrome?

Answer 93

Scapular malposition, Inferior medial border prominence, Coracoid pain, and dysKineisias. Associated with overuse syndrome and fatigue

Question 94

What scapular muscles should be targeted for rehab?

Answer 94

Focus on rhomboid major and minor, Upper/middle/lower trap muscles, SA, and RC muscles. Push up plus activates SA effectively, prone flexion overhead activates upper and middle trap

Question 95

Define snapping scapula.

Answer 95

Attributed to friction between the mobile scapula and attached soft tissues. A general friction sound is nonpathalogic. Sounds associated with pain are thought to be pathologic. Tx with strengthening to scapular muscles

Question 96

How are clavicle fractures classified?

Answer 96

According to location. Middle third are most common (80%).

Question 97

What nerve is most frequently injured with a fracture of the clavicle?

Answer 97

Ulnar nerve, as it passes between the first rib and fractured clavicle.

Question 98

When should shoulder motion be initiated in closed treatment of clavicular fracture?

Answer 98

Usually require 6 weeks of immobilization for union to occur. Surrounding joints should be used immediately.

Question 99

What are the most commonly injured nerves during proximal humerus fracture?

Answer 99

The axillary and suprascapular nerves. Remember, the radial nerve is injured in humeral shaft fractures. Usually all of these injuries heal on their own.

Question 100

What is the conservative treatment of proximal humerus fractures?

Answer 100

Early ROM is critical. Surrounding joints are mobilized immediately, pendulum exercises are initiated as soon as tolerable for stable one part fractures. Once the fractured segment is shown to move as one unit with gentle ROM exercises, PROM is initiated. Early stability is usually noted at 2-3 weeks.

Question 101

How is the spinal accessory nerve usually injured?

Answer 101

tumor, surgical procedures in the posterior triangle, and stretch/whiplash injuries. Typically present with a drooping shoulder girdle, winging of the scapula that is produced during abduction (SA winging usually is noticeable in flexion).

Question 102

What are common sites of entrapment of the suprascapular nerve?

Answer 102

Below the transverse scapular ligament, causing supraspinatus and infraspinatus weakness. Under the spinoglenoid ligament, causing weakness to the infraspinatus only.

Question 103

What nerve is most commonly injured after anterior shoulder dislocation?

Answer 103

Axillary nerve

Question 104

What is rucksack palsy?

Answer 104

Injury to the upper trunk of the brachial plexus or long thoracic nerve. Originally associated with soldiers in Vietnam who carried their packs or rucksacks loaded with ammunition.

Question 105

What is thoracic outlet syndrome?

Answer 105

compression of the neurovascular structure between the neck and axilla.

Question 106

Describe the various tests used to evaluate patients with TOS.

Answer 106

Adson maneuver - palpate radial pulse in abducted and extended arm. Extend and ER arm as patient rotates head toward examiner and takes a deep breath. An absent pulse suggests compressed subclavian artery. Allen test - same as adson's test except arm is abducted to 90* and elbow is flexed to 90*. Patient turns their head away. Roos test: holds both arms in allen test position and rapidly open and close fingers for 3 minutes. Wright test: hyperabduct arm above head to determine compression between the first rib and the clavicle

Question 107

How many tests should be performed in the TOS clinical exam?

Answer 107

One way to decrease the false-positive tests is to perform 3 tests If 3 or more are performed, the false positive falls to 2%. Even with this cluster, sensitivity ad specificity are 72% and 53%

Question 108

Describe the clinical findings of a patient with Pancoast's tumor.

Answer 108

May compromise the C8-T1 nerve roots via compression from the apex of the lungs. Presenting symptoms are sensory changes in the medial forearm and hand (4th and 5th digits). Other signs may include intrinsic muscle wasting and night pain.

Question 109

What is Horner Syndrome?

Answer 109

Ipsilateral involvement of the sympathetic chain fibers, causing sunken eyeball, ptosis, miosis (contraction of the pupil), anhydrosis, and flushing of the face