Upper limb problems Flashcards
1
Q
Shoulder joint type of joint
A
Ball and socket synovial joint
2
Q
Shoulder joint depends on what factor for stability
A
Surrounding muscles - especially rotator cuff muscles
3
Q
Shoulder joint is the articulation of
A
Head of humerus with glenoid fossa of the scapula
4
Q
Importance of the glenoid labrum
A
Deepens the glenoid fossa to allow more stability and shock absorption
5
Q
Why is the shoulder joint the most commonly dislocated joint
A
Because the humeral head is much bigger than the glenoid fossa
= decreased stability
6
Q
What is a joint capsule
A
Fibrous sheath which encloses the structures of the joint
7
Q
Borders of the joint capsule of the shoulder
A
From anatomical neck of the humerus to the border of the glenoid fossa
8
Q
What is at the inner surface of the joint capsule of the shoulder
A
Synovial membrane producing synovial fluid
Synovial Bursae
9
Q
Function of bursae
A
To reduce friction, acting as a cushion between tendons and other joint structures
10
Q
What are the bursae in the shoulder joint
A
Subscapular bursa
Subcoracoid bursa
Subcacromial bursa
Subdeltoid bursa
11
Q
Function of the subacromial bursa
A
To protect the supraspinatus from wear between the humeral head and acromion
12
Q
Function of the subscapular bursa
A
To protect the subscapularis from wear and tear during movement at the shoulder joint
13
Q
Which shoulder bursa is the most commonly inflamed
A
Subacromial bursa
14
Q
Name the rotator cuff muscles
A
Subscapularis
Supraspinatus
Infraspinatus
Teres minor
15
Q
Main common function of the rotator cuff muscles
A
Pulls the humeral head into the glenoid fossa to provide a stable point for deltoid muscle to abduct the arm
16
Q
Innervation of supraspiantus
A
suprascapular nerve
17
Q
Innervation of infraspinatus
A
Suprascapular nerve
18
Q
Innervation of subscapularis
A
Upper and lower Subscapular nerve
19
Q
Innervation of teres minor
A
Axillary nerve
20
Q
Function of the supraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)
A
abduct arm 0-15 degrees
21
Q
Function of infraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)
A
Laterally rotates the arm
22
Q
Function of teres minor (except from providing a stable fulcrum for deltoid to abduct arm)
A
Laterally rotates the arm
23
Q
Function of subscapularis (except from providing a stable fulcrum for deltoid to abduct arm)
A
The ONLY rotator cuff muscle that medially rotates the arm
24
Q
What are the ligaments of the shoulder joints
A
Glenohumeral ligament
Coracoacromial ligament
Coracohumeral ligament
Transverse humeral ligament
25
The joint capsule of the shoulder is formed from which ligament
Glenohumeral ligament
26
Function of glenohumeral ligament
Main stabilizer of the joint
Prevents anterior dislocation
27
Function of coracoacromial ligament
Prevents superior dislocation of the humeral head
Roof of subacromial space
28
Function of transverse humeral ligament
Holds the tendon of long head of biceps in the inter tubercular groove
29
Describe how the abduction of the arm is performed
1. FIrst 0-15 degrees performed by supraspinatus
2. Middle fibres of the deltoid are then responsible for the next 15-90 degrees
3. Past 90 degrees, the scapula needs to be rotated which is performed by trapezius and serratus anterior
30
Extension of the shoulder is performed by
Posterior deltoid
Latissimus dorsi
Teres major
31
Flexion of the shoulder is performed by
pectoralis major
anterior deltoid
coracobrachialis
biceps brachii weakly assists
32
Adduction of the shoulder is performed by
Pectoralis major
Latissimus dorsi
Teres major
33
Shoulder dislocation is most commonly seen in
Sporty younger patients
34
Most common type of shoulder dislocation
Anterior shoulder dislocation - humeral head anterior to glenoid
35
Mechanism of injury for anterior shoulder dislocation
Fall with shoulder in external rotation
36
complication for anterior shoulder dislocation
Damage to axillary nerve
Shoulder instability
37
Which nerve is most at risk of damage from anterior shoulder dislocation
Axillary nerve
38
What is required to assess axillary nerve injury
Regimental badge area sensory assessment
39
How may shoulder instability occur after shoulder dislocation
Due to
- Bankart lesion
- Hillsach lesion
40
What is Bankart lesion
Damage to glenoid labrum
41
What is Hillsach lesion
posterolateral humeral head depression fracture
42
Injury mechanism of posterior shoulder dislocation
Fall with shoulder in anterior location
Direct blow to anterior shoulder
43
Injury mechanism of inferior shoulder dislocation
Shoulder forced into hyperabduction
44
Why should you do a prompt neuromuscular assessment of a patient with inferior shoulder dislocation
Because it is close to the brachial plexus
45
Symptoms of shoulder dislocation
Severe shoulder pain
Inability to move shoulder
46
Clinical signs of shoulder dislocation
Axillary nerve injury
- weakness of shoulder abudction
- Loss of sensory in regimental badge area
Anterior shoulder dislocation - externally rotated and abducted
Posterior shoulder dislocation - internally rotated and adducted
47
Investigations for shoulder dislocation
Xray - AP and Oblique
MRI arthrogram (if suspect Bankart lesion)
Regimental badge area sensory assessment
Extension lag test
48
Why should both AP and oblique Xray be used to investigate shoulder dislocation
Because posterior dislocation is difficult to see on AP xray
49
Xray sign of posterior shoulder dislocation
Light bulb sign
50
What is the extension lag test
Elevate the patient's arm to near full extension
Ask the patient to maintain the position
If arm drops = deltoid is weak = axillary nerve damage
51
Management for shoulder dislocation
Analgesia
Closed reduction under sedation / open reduction
52
Post reduction management for shoulder dislocation
Analgesia
Rehabilitation
53
Recurrent dislocation (shoulder instability) risk is higher in
younger patients
54
What genetic syndromes can cause ligamentous laxity hence atraumatic shoulder instability
Ehler Danlos
Marfan's
55
Management for traumatic shoulder instability
Bankart repair surgery
56
What tests can be used to check for shoulder instability
Posterior and anterior drawer test
Sulcus sign
Posterior and anterior apprehension test
57
Describe the posterior apprehension test
1. Patient in supine
2. Place the patient's arm in flexion, adducted, and internally rotated
3. Apply a posteriorly directed force
4. Pain / sense of instability = positive
58
Describe the anterior drawer test
1. Patient in supine / sitting
2. Shoulder is held in abduction, flexed, and externally rotated
3. Immobilise the scapula with left hand
4. Grab the proximal upper arm and pull it anteriorly
Positive = pain / instability
59
Describe the sulcus sign
1. Patient sitting
2. Grab the patient's forearm below the elbow and pull it inferiorly
Positive = depression under the acromion
60
Shoulder impingement most commonly affects
under 25
Sporty
61
What is shoulder impingement
Inflammation of the rotator cuff tendons as they are compressed in the subacromial space during movement
62
Causes of shoulder impingement
Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
63
Which rotator cuff tendon is the most commonly inflamed in shoulder impingement
Supraspinatus
64
Symptoms of shoulder impingement
Pain radiating to deltoid and upper arm
Tenderness at lateral edge of acromion
Difficulty reaching over head
65
Investigations for shoulder impingement
Hawkins Kennedy test
Jobe's
Xray - AP and oblique
66
Xray result for shoulder impingement
Normal
This helps rule out joint arthritis
67
Describe the Hawkins Kennedy test
Internally rotating the flexed shoulder
68
Describe the Jobe test
1. Patient raises both his arms to scapular level
2. Arms internally rotated so thumb points at the floor
3. Ask patient to resist the upcoming force
4. Examiner apply a downward directed force to the arm
Pain = positive
69
Management for shoulder impingement
Rest
Analgesia
NSAID
Physiotherapy
Subacromial injection of steroid
Surgery if indicated
70
When is subacromial injection of steroids used indicated in shoulder impingement
Symptoms does not settle after analgesia / NSAID
Subacromial bursitis
71
How many times can subacromial injection of steroid be used in shoulder impingement
3
72
When is surgery indicated in shoulder impingement
If after 6 months of conservative management the symptoms continue
73
Tendons of rotator cuff muscles most commonly tear in
> 40 years old
74
Tendons of rotator cuff can tear with minimal or no trauma due to
Degenerate changes in tendon
75
What is a classic history of rotator cuff tear
Sudden jerk (holding a rail on a bus which suddenly stops) in a patient over 40, with subsequent pain and weakness
76
Can rotate cuff tear be asymptomatic
Yes, in patients over 60, it can be asymptomatic
77
Which tendon of rotator cuff muscle is the most commonly torn
Supraspinatus
78
Extent of tears of rotator cuff muscle can be
Partial or full thickness
79
Large tear of rotator cuff muscle can
Extend from supraspinatus to subscapularis and infraspinatus
80
Symptoms of rotator cuff tear
Can be asymptomatic in elderly
Pain radiating down the arm
Weakness
81
What weaknesses can be seen in rotator cuff tear
Initiation of abduction - supraspinatus
Internal rotation - subscapularis
External rotation - infraspinatus
82
Clinical signs of rotator cuff tear
Weaknesses
Muscle wasting of supraspinatus
83
Investigations for rotator cuff tear
Jobe's test
Xray
US if good ROM
MRI if reduced ROM
84
Treatment for rotator cuff tear
Surgery (controversial)
Physiotherapy
Subacromial injection for symptomatic relief
85
Why is rotator cuff repair surgery controversial
Because failure of repair occurs in 1/3 of cases
86
Goal of physiotherapy for rotator cuff tear
Strengthen the other muscles to compensate for the loss of supraspinatus
87
complications of rotator cuff tear
Torn rotator cuff = deltoid can pull the head of humerus upwards
Abnormal forces on glenoid leads to OA
88
What is adhesive capsulitis (frozen shoulder)
Inflammation and fibrosis of the shoulder joint capsule leading to contracture of the shoulder joint
89
Risk factors for adhesive capsulitis
40-50
Female
Diabetes
Hypercholesterolaemia
Dupuytren's disease
90
Stages of adhesive capsulitis
1. Freezing stage - pain
2. Frozen stage - pain subsides but stiffness increases
3. Thawing stage - stiffness resides -> recovery of shoulder motion
91
How long does freezing stage last in adhesive capsulitis
2-9 months
92
How long is stiffness felt in adhesive capsulitis (frozen stage)
4-12 months
93
What is the main clinical sign of adhesive capsulitis
Loss of external rotation
94
OA of the shoulder can also cause loss of external rotation. How do you differentiate between OA and adhesive capsulitis
OA occurs in much older patients
95
Management of adhesive capsulitis
Self limiting
Physiotherapy
Analgesia
Glenohumeral injection can help in painful stage
Manipulation under anaesthetic / surgical capsular release if indicated
96
When is manipulation under anaesthetic / surgical capsular release indicated in adhesive capsulitis
If the patient cannot tolerate the functional loss due to stiffness
97
What are the other causes of shoulder pain
Inflammation of the tendon of long head of biceps
Tears in glenoid labrum (SLAP lesions)
Referred pain
98
Complication of inflammation of the tendon of long head of biceps
Popeye deformity - abnormal shortening of bicep muscles due to rupturing of the inflamed tendon
99
How can tears in glenoid labrum be detected
MRI arthrogram
100
What conditions can cause referred pain to the shoulders
Neck problems
Diaphragmatic irritation.- biliary colic, hepatic, subphrenic abscess
101
Name A - G of the humerus
A - anatomical neck
B - Greater tuberosity
C- Surgical neck
D - Humeral head
E - Intertubercular groove
F - Lesser tuberosity
G - Deltoid tuberosity
102
Name A - F of the shoulder joint
A - acromion process
B - articular cartilage of humeral head
C - Humerus
D - Glenoid fossa
E - Scapula
F - Coracoid Process
103
The greater tubercle of humerus is an attachment point for
Supraspinatus muscle tendon
Infraspinatus muscle tendon
Teres minor muscle tendon
104
The lesser tubercle of humerus is an attachment point for
Subscapularis muscle tendon
105
Name A-G
A - supraspinatus muscle
B - greater tuberosity
C - lesser tuberosity
D - Subscapularis muscle
E - Supraspinatus muscle
F - Infraspinatus muscle
G - Teres minor
106
The inter tubercular groove of the humerus is an attachment point for
Long head of biceps (runs along the groove)
Pectoralis major
Latissimus dorsi
Teres major
107
Name A-D
A- intertubercular groove
B - Pectoralis major
C - teres major
D - Latissimus dorsi
108
Deltoid tuberosity is the attachment point for
Deltoid muscle
109
This image is describing the course of
Radial nerve
110
Describe the course of radial nerve
1. Arises from the posterior cord of brachial plexus in the axilla region
2. Descends down the arm along the radial groove
3. Then wraps around the humerus laterally
4. then reaches the forearm by traveling anteriorly to the lateral epicondyle of the humerus, through the cubital fossa.
111
Radial groove is at the posterior / anterior aspect of humerus
Posterior
112
What structures run along the radial groove
Radial nerve
Radial artery
113
The borders of cubital fossa
Superior - transverse line between medial and lateral epicondyles
Medial - Pronator teres
Lateral - Brachioradialis
114
Name A-C
A - Pronator teres
B - Transverse line between medial and lateral epicondyle
C - brachioradialis
115
What muscles attach to the anterior shaft of humerus
Coracobrachialis
deltoid
brachialis
brachioradialis
116
Name A-E
A - Subscapularis (attached to lesser tubercle not the inter tubercular groove)
B - teres major
C - Coracobrachilais
D - Triceps brachii
E - Brachialis
117
Name this muscle
Brachioradialis
118
Attachment point
119
Which muscles attach to the posterior aspect of humeral shaft
Medial and lateral heads of triceps brachii
120
Name A-E
A - Lateral head of triceps
B - Medial head of triceps
C - Long head of triceps
D - triceps tendon
E - Ulna
121
The long head of triceps does not insert onto the posterior humeral shaft. Where does it origin and attach to
Originate from infraglenoid tubercle of scapula
Insert onto Posterior surface of the olecranon process of the ulna
122
Name A-G
A - olecranon fossa
B - Lateral epicondyle
C - Trochlea
D - medial epicondyle
E - Coronoid fossa
F - Radial fossa
G - capitulum
123
Which nerve passes between the medial epicondyle and olecranon
Ulnar nerve
124
Name A-D
A- Medial epicondyle
B- Ulnar nerve
C- Olecranon
D- cubital tunnel retinaculum
125
What is biceps tendinopathy
Inflammation of long head of biceps tendon
126
Cause of biceps tendinopathy
Overuse
Instability
Impingement
Trauma
127
Symptoms of biceps tendinopathy
Pain at anterior shoulder radiating to elbow
Pain worse by movements
128
What movements worsen the pain of biceps tendinopathy
Shoulder flexion
Forearm supination
Elbow flexion
129
Clinical signs of biceps tendinopathy
Tenderness
Pop-eye sign
130
Investigations for biceps tendinopathy
US
131
Management for biceps tendinopathy
Physiotherapy
Surgical repair (controversial)
132
Why is surgical repair for biceps tendinopathy controversial
High risk of neurovascular complication
133
Where does proximal humerus fracture usually occur
Surgical neck of humerus
134
Proximal humerus fracture is common in
Osteoporotic bone - low energy injury
135
Symptoms of proximal humerus fracture
Pain
Swelling
Reduced ROM
136
Signs of Proximal humerus fracture
Extensive bruising of chest, arm and forearm
Axillary nerve injury
Radial nerve injury (less common)
137
Which nerve is the most commonly damaged in proximal humeral fracture
Axillary nerve
138
Apart from axillary nerve, which other nerve can be damaged by proximal humeral fracture
Radial nerve but less common
139
Radial nerve damaged at the axilla region due to proximal humeral fracture / shoulder dislocation can lead to
Tricep brachii weakness or paralysis - unable to extend forearm
Wrist drop
loss of sensation over
- lateral and posterior arm
- posterior forearm
- dorsal surface of the lateral three and a half digits.
140
Investigations for proximal humerus fracture
Xray - AP and lateral
CT
MRI if need to identify rotator cuff injury
Regimental badge area sensory assessment
Extension lag test
141
Management for proximal humeral fracture
Collar and cuff
ORIF
replacement
142
Humeral shaft fracture can present as
Spiral
Oblique
Transverse
Comminuted
143
What type of fracture does the image show
Comminuted fracture
144
What type of fracture does this image show
Compound fracture
145
Which nerve is most likely to be damaged by humeral shaft fracture
Radial nerve
146
Symptoms of humeral shaft fracture
Pain
Extreme weakness
147
Signs of humeral shaft fracture
Radial nerve injury
-wrist drop
-reduced sensation in the anatomical snuffbox
-may have weakness in triceps brachii but not paralysis
148
Why does wrist drop occur in radial nerve injury
Because the extensor muscles of the posterior forearm -> cannot extend the wrist and fingers
149
Where is the anatomical snuff box
triangular depression found on the lateral aspect of the dorsum of the hand
150
investigations for humeral shaft fracture
Xray - AP and lateral
Assess radial nerve injury
151
Management of humeral shaft fracture
Humeral brace
IM nail
ORIF with plate fixation (rare)
152
IM nail for humeral shaft fracture is indicated in
osteoporotic bone
153
Name A to J
A - lateral epicondyle
B - Medial epicondyel
C - Radial fossa
D - Trochlear
E - Capitulum
F - Olecranon
G - Trochlear notch
H - Coronoid process
I - radial notch
J - Radial tuberosity
154
The olecranon is an attachment point for
Long head of triceps brachii
155
Coronoid process of ulna is an attachment point for
Brachialis
156
Brachialis origin and insertion point
Anterior shaft of humerus -> coronoid process of ulna
157
Name A - I
A - Olecranon
B - Trochlear notch
C - Coronoid process
D - Radial notch
E - Ulnar tuberosity
F- Radial tuberosity
G - Interosseuous border
H - styloid process of ulna
I - styloid process of radius
158
What is the interosseous border
Edge of a bone to which a fibrous membrane is attached so the bone is attached to the adjacent bone
159
Name A - C
A - Radial notch of ulna
B - Interosseous membrane
C- Ulnar notch of radius
160
Radial tuberosity is an attachment point for
Biceps brachii - short and long head
161
Name the superficial contents of cubital fossa (lateral to medial)
(Really Need Beer To Be At My Nicest)
Radial Nerve
Biceps Tendon
Brachial Artery
Median Nerve
162
What are the superficial veins in cubital fossa
Medial cubital vein
Cephalic vein
Basilic vein
163
Which other nerve can be seen deep in the cubital fossa
Radial nerve
164
What does brachial artery bifurcate into and where
Radial and ulnar arteries
Birfurcates at the apex of cubital fossa
165
Name A-H
A - Brachial artery
B - Median Nerve
C - Pronator. teres
D - Ulnar artery
E - Biceps tendon
F - Radial Nerve
G - Brachioradialis
H - Radial artery
166
Name A-D
A - Bicipital aponeurosis (aponeurosis of biceps brachii)
B - Cephalic vein
C - Basilic vein
D - Median cubital vein
167
Cubital fossa is a common site for
venopuncture and siting of peripheral venous cannulas
Due to the superficial veins being easily accessible
