Upper Extremity Flashcards
Describe goutellier’s classification:
Describes amount of fatty infiltration of a tendon
1: fatty streaks
2: more muscle than fat
3: equal amounts of muscle and fat
4: more fat than muscle
Describe the DASH score:
Hhn
What are the shapes of rotator cuff tears? How are they repaired
Crescent: direct repair (end to end)
U-shaped: require side-to-side repair first, followed by end to end repair
L-shaped: use margin convergence in repair
How do you classify rotator cuff tears based on tear size?
Small: 0-1cm
Medium: 1-3cm
Large: 3-5cm
Massive: >5cm or involving more than 2 tendons
What is the Patte classification of rotator cuff tears? Why is it Lapner’s favourite?
Defines cuff retraction in the coronal plane.
Stage 1: proximal stump close to bony insertion
Stage 2: proximal stump at level of humeral head
Stage 3: proximal stump at level of glenoid
He thinks its the most reliable classification of how hard a tear will be to fix
Describe Hawkins test:
Tests for subacromial(?) impingement
FF 90 deg, elbow flexion 90deg
IR in this position causes pain
Tests for impingement of GT under CH ligament
Where do the long and short heads of biceps brachii insert? What is each responsible for?
Short head: more distally on biceps tuberosity.
- Responsible for flexion
Long head: attaches more proximally and ulnarly on biceps tuberosity
- Responsible for supination
What is the main clinical exam for distal biceps tendon rupture?
Hook test (remember to hook lateral to medial, otherwise you could get fooled by the biceps aponeurosis (lacertus fibrosis), which may still be attached)
What is the biceps aponeurosis (lacertus fibrosus) continuous with?
Fascia of the forearm
What happens to strength with non-operative management of distal biceps tendon rupture?
40-50% loss of supination
30% loss of flexion
15% loss of grip strength
What are the repair options for distal biceps tendon rupture?
One incision vs. two incision
What is the classic patient population of biceps tendon rupture?
Middle aged (40-50yr old) male labourer
What are the most common complications of one incision and two incision techniques of distal biceps tendon repair?
One incision: Synostosis more common
Two incision: Lateral antebrachial cutaneous nerve more common, radial nerve also more common in this one
Name 3 complications of distal biceps tendon repair?
Nerve damage: - Lateral antebrachial cutaneous nerve most common - Radial nerve damage Synostosis Heterotopic ossification
What will be the contrast enhanced MRI or Arthrogram finding in multidirectional instability?
Capacious capsule with no labral tear
What is the presentation on MDI.
Young patient, overhead throwing athlete, laxity/ dislocations
Will have positive sulcus, apprehension and impingement signs
What is the kocher interval for distal humerus?
Anconeus & ECU (posterolateral approach)
What is the Kaplan interval for distal humerus?
ECRB & EDC (direct lateral)
What are the lateral approaches/intervals for the distal humerus?
Kaplan, EDC split, kocher
What is the interval for the medial approach to the distal humerus?
Pronator teres split.
Previously elevation of the flexor/pronator mass, but PT split shown to have less damage to flexor/pronator mass
Clinical vignette:
Young to middle aged patient with posterior shoulder pain with overhead activities and carrying havy objects below the shoulders. Hx of overhead throwing sports
SLAP tear
Name 3 indications for total elbow arthroplasty:
RA Primary OA Post-traumatic OA Fracture Chronic instability
Total elbow arthroplasty has the best survival in patients done for what indication?
RA
What is the functional range of motion of the elbow required to perform basic ADLs?
30-130deg arc of flexion/extension
100 degree arc of pronation/supination (50deg each way)
What is a SLAP tear?
Superior Labrum from Anterior to Posterior
What is the classification of SLAP tears?
Snyder classification:
Type 1: degenerative fraying
Type 2: degenerative fraying involving biceps
Type 3: bucket handle tear not involving biceps
Type 4: bucket handle tear involving biceps
Type 5: SLAP w/ anterior labral tear (Bankart)
Type 6: superior flap tear
Type 7: SLAP w/ capsular injury
What is the most common type of SLAP tear?
Snyder type 2: degenerative fraying involving biceps
What are the stages of calcific tendonitis?
Pre-calcific Calcific - Formative - Resorptive Post-calcific
When is pain present in calcific tendonitis?
Resorptive phase
What are the different types of calcific tendonitis? Why is it important to differentiate them?
Chronic degenerative (aka from tendon degeneration)
- Calcification is at the enthesis (insertion onto bone) & does not heal
Acute
- Calcifications are midsubstance and will heal
Important to tell difference because of underlying etiology and management
At what phase and how do you treat calcific tendonitis surgically?
Needle aspiration - resorptive phase
Extra-corporeal shock waver therapy - formative
Operative - formative
What are the stages of frozen shoulder?
Freezing/painful (6wks - 9mos)
Frozen/stiff (4-9+ mos)
Thawing (5-26mos)
Generally resolved by 18mos
What are the clinical characteristics of each stage of frozen shoulder?
Freezing: pain with decreasing ROM
Frozen: decreased ROM, no pain
Thawing: gradual return of ROM
What is the first line management of calcific tendonitis?
NSAIDs & PT
What is the classification system of RA of the elbow?
Larsen or Mayo classification
Describe the Mayo classification of RA of the elbow?
Grade 1: minimal radiographic change
Grade 2: mild decreased joint space and architectural change
Grade 3: moderate to severe architectural changes
Grade 4: loss of ulnohumeral joint and major architectural changes
What is the pattern of RA and OA joint space loss?
RA: symmetric
OA: asymmetric
Where in the elbow does OA (RA?) start?
Starts at radiocapitellar joint, then progresses to ulnohumeral
What is the management of Mayo grade 1-2 elbow RA?
Arthroscopic synovectomy
What is the management of Mayo grade 3-4 elbow RA?
Total elbow arthroplasty
What are the kinds of total elbow arthroplasty systems? What is the best?
Hinged/constrained
Unconstrained
Semi-constrained/sloppy-hinge
- Best is semi-constrained
What are the risk factors for frozen shoulder?
Diabetes Thyroid disorders (autoimmune etiology) Previous surgery (lung & breast) Prolonged immobilization Extended hospitalization
What is the most important stabilizer on the medial side of the elbow?
Depends on angle of flexion, but overall, Central band of the anterior bundle.
This is correct according to Pollock. See King article. NOT the anterior band of the anterior bundle
What is the essential lesion of elbow instability?
Lateral collateral ligament injury (specifically lateral ulnar collateral ligament)
