Upper limb surgical repair Flashcards
Bone on bone contact in the shoulder can lead to (2)
osteophytes and osteoarthritis
Muscle released in shoulder replacement (tendon)
subscapularis
muscle released in reverse shoulder replacement
deltoid
Plane between deltoid and pectoralis major
anterior inter nervous plane
Deltoid nervous supply
axillary nerve
Pectoralis major nervous supply (2)
medial and lateral pectoral nerves
vein in deltopectoral groove
cephalic vein
groove between deltoid and pectoralis major
deltopectoral groove
proximal end of deltopectoral groove
coracoid process
deltopectoral groove is infero lateral to what
clavicle
what is between cephalic vein, deltoid and pectoralis major (2)
fascia over deltoid and pectoralis major
once deltopectoral groove is incised what is retracted
deltoid
once deltoid is retrancted what is incised
subscapularis tendon
what is inferior to subscapularis tendon
vessels
where is a drill hole placed when subscapularis is released
coracoid process
conjoint tendon (2)
short head of biceps brachii and coracobrachialis
what happens to conjoint tendon
released with tip of coracoid process
what is between the subscapularis and teres major
vessels
what happens to vessels inferior to subscapularis
clamped
once subscapularis is incised what happens to it (2)
reflected and sutures put in place
once subscapularis is reflected what is incised
joint capsule
joint capsule is incised to reveal (3)
head of humerus, glenoid fossa, posterior glenoid labrum
what runs medial to coracoid process
axillary sheath
what is in the axillary sheath (2)
axillary vessels and brachial plexus
when is axillary sheath pulled closer to coracoid process
abducted shoulder
nerve closest to area of shoulder replacement
musculocutaneous nerve
what nerve lies inferior to subscapularis
axillary nerve
muscles inferior to axillary nerve (superficial to deep 2)
latissimus dorsi and teres major
what moves the area of work away from axillary nerve
shoulder external rotation
rotator cuff tears which muscle contracts strongly to attempt abduction
deltoid
deltoid contraction but rotator cuff tear what happens (3)
humerus pulled superiorly towards acromion, scapula externally rotated, clavicle elevated
what angle allowed in abduction with rotator cuff tear
45 degrees
what happens to abduction at 90 degrees with partial rotator cuff tear
unable to hold resistance
what can communicate in rotator cuff tear
shoulder joint and subdeltoid bursa
what can occur in rotator cuff tear (3)
thickened edematous biceps brachii tendon, retracted tendon, needs to be repaired with surgery
bicep brachii tendon repair if edges fresh (3)
notch made in humerus, attach with drill holes, strong sutures
Open acromioplasty removes (2)
tip of acromion and most of coracoacromial ligament
where is incision made to inspect rotator cuff for tears in acromioplasty
T incision in deltoid
what portion of acromion removed in acromioplasty
anterolateral inferior
what tool used in acromioplasty
osteotome
deltoid reattachment acromioplasty suture origin
acromioclavicular joint capsule
deltoid reattachment acromioplasty suture insertion (2)
fibrous stump of coracoacromial ligament or wires and small drill holes in acromion
Arthroscopic acromioplasty setup (6)
lateral decubitus position, hips stabilised, padding between knees and ankles, arm extended and abducted, skin traction, screen visualisation
what is inserted from arthroscopic acromioplasty (3)
arthroscope, cannula, suction drain
where is burr placed
with cannula
where is arthroscope placed
below posterior angle of acromion
where is the burr and suction drain placed
through cannulas in anterior incision
tool used in arthroscopic acromioplasty
power burr
how is acromion portion removed arthroscopically
cannula, releasing coracoacromial ligament
What is done to observe bursa
burscopy
what can burscopy reveal
bursitis
inflamed bursa
bursitis
subacromial impingement diagnostic features (5)
pain at night, pain with activity, MRI, positive impingement test, weakness
no subacromial impingement arthroscopic view (medial to lateral 3)
rotator cuff, biceps tendon, top of humerus
what can bone spurs cause (3)
bursitis, tendonitis, rotator cuff tears
what happens when bone spur is removed
pressure on rotator cuff released
how is rotator cuff attached in arthroscopic rotator cuff repair
sutures and anchors to humerus
normal gleno humeral arthroscopic view
biceps tendon
abnormal gleno humeral arthroscopic view
torn biceps tendon
how are loose bodies from torn biceps tendon removed
grabber
average width of sternal end of clavicle
22.6 mm
average width of acromioclavicular end of clavicle
21.1 mm
at risk average width of clavicle
12.0 mm
average at risk length of clavicle
138.4 mm
subclavian artery average width
0.42 mm
subclavian vein average width
0.33 mm
safe trajectory through clavicle
superiorly
dangerous trajectory through clavicle
anteriorly
dangerous clavicular trajectory at risk elements (superficial to deep)
subclavian vein, scalenus anterior, subclavian artery, brachial plexus
what could lead to a proximal humeral fracture
fall
what is one way of fixing proximal humeral fracture
plate and screws
which nerve runs around the humerus
axillary nerve
what is important to do before proximal humeral fracture surgery (2)
measuring and marking nerve
At what angle is the nerve felt deep to deltoid, run along the bone
Cobb
What is one way to visualise the axillary nerve
arthroscope
for proximal humeral fracture repair where is the plate slipped
deep to deltoid
where are K wires positioned for proximal humeral fracture repair (2)
top and bottom
what is used to reduce shaft to plate in proximal humeral fracture repair
screws
Once screws are in place for proximal humeral fracture repair what is done
screws are locked
How many screws at top and bottom of plate in proximal humeral fracture repair
4 each
In proximal humeral fracture repair what arteries need to be avoided (3)
posterior and anterior humeral circumflex. arcuate
Which artery runs in the intertubecular groove of the humerus
anterolateral branch of anterior humeral circumflex
what is between the greater and lesser tubercles of the humerus
intertubecular groove
which is bigger anterior or posterior humeral circumflex arteries
posterior
which artery does the anterior and posterior humeral circumflex arteries branch from
axillary
types of proximal humeral fracture repair (3)
3 part, 4 part, valgus 4 part
chance of 3 part proximal humeral fracture repair
12-25%
chance of 4 part proximal humeral fracture repair
21-75%
chance of valgus 4 part proximal humeral fracture repair
8-26%
Predictors of humeral head ischaemia (3)
metaphyseal head extension calcar less than 8 mm (97% PPV), loss of integrity of medial hinge, fracture pattern (anatomic neck)
When is the humeral head likely not viable for proximal humeral fracture repair
lateral head displacement
When will a longer plate be required
proximal and shaft fracture
what is a SLAP lesion
superior labral anterior posterior
grades of SLAP lesion
I-IV
How can SLAP be diagnosed
MRI
Paralabral cysts (4)
superior, posterior, inferior, anterior
what can be involved with paralabral cysts (2)
suprascapular notch extension, spinoglenoid notch involvement
How can paralabral cysts be diagnosed
MRI
what is released to reveal spinoscapular nerve
TSL
types of clavicular dislocation
I-VI
type I clavicular dislocation
acromion inferior
type II clavicular dislocation
acromioclavicular ligament torn
type III clavicular dislocation
acromioclavicular and coracoclavicular ligaments torn
type IV clavicular dislocation
coracoclavicular ligament torn
type V clavicular dislocation
acromioclavicular and coracoclavicular ligaments torn, clavicle shifted superiorly
type VI acromioclavicular and coracoclavicular ligaments torn
acromioclavicular and coracoclavicular ligaments torn, clavicle shifted inferiorly, distal clavicle behind tendons of biceps brachii and coracobrachialis
fixing clavicular dislocation (2)
screw through clavicle and coracoid process
Where does the clavicle normally fracture
lateral 1/3
What produces a popeye arm
proximal long head of biceps tendon tear
What indicates proximal long head of biceps tendon tear
active flexion of elbow
what is another name for a torn tendon
avulsed
what needs to be reflected for proximal long head of biceps tendon tear repair (2)
deltoid and pectoralis major
where are stitches placed for proximal long head of biceps tendon tear repair
biceps tendon and acromion
what technique is used for bicep brachii insertion tear repair
pullout wire trapdoor technique
where is a trapdoor placed for insertion of biceps tendon repair
radius
who came up with pullout wire trapdoor technique
Bunnell, Bovd, Anderson
what sutures are used for bicep brachii belly tear
mattress sutures
what is a distal humeral fracture called
Holstein Lewis humeral fracture
What is at risk with a Holstein Lewis humeral fracture (2)
lateral intermuscular septum and radial nerve
Which shoulder dislocation occurs 30% of the time
anterior inferior
dislocated shoulder can result in
proximal humeral fracture
what happens secondary to axillary nerve injury
deltoid wasting and weakness
Hilton’s law (3)
nerves supply a muscle moving a joint, nerves supply articular branches to joint, nerves supply skin overlying muscle insertion
Axillary nerve roots
C5-C6
dorsal scapular nerve roots
C5
Subclavius nerve roots
C5-C6
Suprascapular nerve roots
C5-C6
Lateral pectoral nerve roots
C5-C7
Musculocutaneous nerve roots
C5-C7
Radial nerve roots
C5-T1
Median nerve roots
C5-T1
Ulnar nerve roots
C7-T1
Upper subscapular branch nerve roots
C5-C6
medial antebrachial cutaneous nerve roots
C8-T1
lower subscapular nerve roots
C5-C6
thoracodorsal nerve roots
C6-C8
medial brachial cutaneous nerve roots
T1
medial pectoral nerve roots
C8-T1
long thoracic nerve roots
C5-C7
to longius colli and scalene nerve roots
C5-C8
