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2 - Ortho: Shoulder Flashcards

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1
Q

What is the criteria for evaluation of pain?

A 
PQRST:
Provocation/Palliation
Quality 
Region/Radiation
Severity Scale
Timing
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2
Q

What are the two ligaments of the coracoclavicular joint? Locations?

A

Conoid (medial)

Trapezoid (lateral)

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3
Q

What are the ligaments involved with sternoclavicular joint?

A

Sternoclavicular Ligaments
Interclavicular ligament
Costoclavicular ligament

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4
Q

What are the 4 joints of the shoulder girdle?

A

Glenohumeral
Acromioclavicular
Sternoclavicular
Scapulothoracic

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5
Q

What tests are you going to use for assessing G-H instability?

A

Apprehension Test
Relocation Test
X-rays (AP, Axillary, Scap-Y view)

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6
Q

What test should be ordered if a Hill-Sachs Lesion is suspected? KNOW THIS

A

A CT scan, helps understand the depth of lesion accurately

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7
Q

What test should be ordered if you are worried about GH capsular instability?

A

MRI arthrogram to get a good look at all the structures

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8
Q

What type of lesion occurs with an anterior dislocation of the shoulder? Known as a tear of necessity (allows shoulder out of Glenoid)

A

Bankart Lesion - antero-inferior tear of the glenoid labrum

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9
Q

What test should be ordered if nerve involvement (most likely axillary nerve) is suspected with GH instability?

A

Test for sensation over deltoid region
Order an EMG for definitive
(Typically these nerve dings resolve on their own)

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10
Q

Immediate treatment options for a dislocated shoulder?

A

Stimson Technique (weighted pendulum off table): relaxes spasm muscles to help prepare for reduction

Traction-counter traction: “water skiing”

FARES: oscillating abduction of the shoulder then external(supination) at (90

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11
Q

What are the most common injuries associated with a traumatic dislocation of the GH joint?

A 
Anteroinferior Labrum (bankart tear)
Anteroinferior GH Ligament
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12
Q

Describe the clinical pathway acronym of a traumatic instability of the GH

A 
"TUBS"
Traumatic 
Unidirectional
Bankart
Surgical intervention
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13
Q

Describe the clinical pathway acronym of atraumatic instability of GH

A 
"AMBRI"
Atraumatic
Multidirectional 
Bilateral instability
Rehabilitation
Imbrication (surgery to tighten stuff)
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14
Q

What is the likelihood of re-dislocation in an adolescent with open growth plates at time of initial injury?

A

100%!!!!!!!!!!!!!!

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15
Q

What is the re-dislocation rate in 18-30 year-olds?

Over 40?

A

55-95%

<10% (Rotator Cuff Tear more common)

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16
Q

What is the original cause of subacromial impingement, describe the progression.

A

Compression of the rotator cuff muscles in the subacromial space by the acromoin, followed by inflammation of the supraspinatus and its tendon most commonly

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17
Q

What are common CCs of a patient who has subacromial impingement?

A

Painful abduction and/or liftting + working overhead
Difficulty throwing
Crepitance or catching on ROM

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18
Q

What are the common tests to dx a subacromial impingement?

A

Neers sign: passive forward flexion over 90 deg. w/ pronation causes pain

Hawkins Test: Elbow @ 90, Internal Rot. and G-h flexion with passive internal provocation

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19
Q

What types of objective testing would you do on a patient with suspected impingement?

A

X-Ray: DJD of AC joint
Arthrogram: Not Necessary, shows capsular tissue well
MRI: for hypertrophy or congenital downsloping acromion

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20
Q

What X-Ray view is necessary for the assessment of Bigliani Classification?

A

AP
Axillary
Scap-Y - allows to look at supraspinous outlet

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21
Q

Describe the Bigliani Classifications

A

Type I: Flat Acromion - Least Likely
Type II: Curved Acromion - More likely
Type III: Hooked Acromion - More likely

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22
Q

What is the first line of treatment for subacromial impingement?

A

PHYSICAL THERAPY ALWAYS FIRST

NSAIDs, maybe steroid injections

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23
Q

What should you do if the steroids, PT, and NSAIDS don’t improve the symptoms of impingement?

A

Arthroscopic (Acromioplasty): shaving the end of the acromion to relieve the impingement problem.

Mumford Procedure: Arthroscopic distal clavicle resection

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24
Q

What is the OIFN of Supraspinatus?

A

Origin: Suprascapular fossa
Insertion: Greater Tubercle of Humerus
Function: Abduction
Innervation: suprascapular nerve

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25
What is the OIFN of Infraspinatus?
Origin: Infraspinous Fossa Insertion: Greater Tubercle Function: Lateral/External Rotation Innervation: Suprascapular Nerve
26
What is the OIFN of Teres Minor?
Origin: Lateral Border of the Scap Insertion: Inferior Greater Tubercle Function: External Rotation, Adduction Innervation: Axillary
27
What is the OIFN of Subscapularis?
Origin: Subscapular Fossa Insertion: Lesser Tubercle Function: Adduction, Internal Rotation Innervation: Sup+Inf Subscapular N.
28
What is the major CC of a Rotator Cuff Tear?
Weakness in active Full ROM in passive Pain @ night, cant throw, radiation to elbow, probs with overhead work
29
What are the two large etiologic theories of rotator cuff tears?
1. Vascular insufficiency at the "critical zone" (supraspinatus insertion point, causing weakness and prone for tearing 2. Neer's theory: Micro-trauma due to chronic impingement in the subacromial space, causing eventual complications.
30
What physical tests can you do if you suspect a rotator cuff tear?
Drop Arm Test - supraspinatus Empty Can strength test - supraspinatus Gerber's Lift-Off test for subscap
31
What types of objective tests can you order for a suspected RTC tear?
X-ray: subluxation of the humerus from the glenoid indicates RTC absence of support (RTC arthropathy. Look for DJD or Spurs or Narrowing MRI: See tear on MRI TQ!! Arthrogram: Follow contrast as it moves to spot points of void in cuff, see tear (unlikely) Ultra sound: to see tear
32
What is a contraindication of ultrasound?
Cardiac implants
33
What is the first line of treatment for a RTC tear/
Abduction sling Physical therapy Meds and Modification of activity
34
What type of CC would make you want to suspect calcific tendonitis? What is it?
Very painful, sudden onset shoulder pain, It is inflammation associated with hydroxyappetitie crystal calcification deposits in the RTC muscle So painful that people get worked up for an MI!!
35
What objective tests can be done to help diagnose calcific tendinitis?
AP X-Ray will show a bone dense mass where muscle should be MRI: Dark Mass looks like fluid but compare to bone cortex!! Same spot as supraspinatus tear (80%) except supraspinatis will show up white?
36
What is the conventional workup for a patient with calcific tendinitis?
Conservative Modalities first!! (NSAIDs, PT, Iontophoresis, Needling (break it up), Cortisone) Open or arthroscopic surgery if all else fails
37
What is involved in the dx of a biceps tendon rupture?
Proximal - popeye deformity | Distal
38
What is the OIFN of the biceps long head
Origin: supraglenoid tubercle Insertion: radial tuberosity Function: supination and flexion Innervation: musculocutaneous n.
39
What is the OIFN of the biceps short head?
Origin: coracoid Insertion: radial tuberosity Funciton: supination and flexion Innervation: Musculocutaneous
40
What types of objective testing would you do for a suspected BCT tear?
MRI
41
What physical test will be done to test for biceps tendinitis
Yergason's test: Arm at side, elbow @ 90, active supination against physician resistance, biceps tendon pain pinpointed
42
Whats involved with a cc that has AC separation?
Pain with ROM Crepitance Visual elevation of the clavicle from the acromion Palpable Deformity Could follow trauma - fall on direct shoulder Could happen spontaneously - suspect infection
43
What is the grading scale for AC separation?
Rockwood Classification 1. Sprain of the AC ligament 2. AC Ligament but CC ligs are intact 3. AC and CC ligs are torn 4. All torn plus posterior displacement of clavicle into trap muscle 5. Massive separation (>100%) with deltoid fascia involvement 6. 5+ clavicle trapped under coracoid
44
What grades of AC separation are operable/non?
123 - skillful neglect (perhaps slinging) and let it try to heal 456 - always operable
45
What is involved with a cc of adhesive capsulitis, diff from RTC tear?
Can't raise arm, different from RTC in that passive ROM is greatly decreased as well.
46
What type of objective tests will be done with an adhesive capsulitis workup
MRI: show loss of axillary pouch or thickening of the anterior capsule
47
What types of treatment will be done for adhesive capsulitis?
Physical Therapy and Medications Last resort will be aggressive manipulation under anesthesia (careful could fracture humerus) Possibly arthroscopic release if manipulation fails
48
What are the stages of adhesive capsulitis?
Freezing Frozen Thawed
49
What is involved with DJD of the shoulder?
Pain, Loss of Motion, Warmth, Crepitance, Loss of strength.
50
What differentiates it from other pathologies?
XRay - loss of roundedness of humeral head, whitening of both surfaces in the bone, loss of joint space You can feel the crepitance in the shoulder with ROM
51
What are the possible treatments for DJD in the shoulder?
First line - meds, injections, PT Surgery (Joint Replacement)
52
What physical test will be done for thoracic outlet suspicion?
The Adson's Test: Cervical Compression, Extend/Sidebend/Rotate head and feel for RadialPulse changes in ipsilateral arm, pain or paresthesias
53
What objective testing can be done for workup of Thoracic Outlet symptoms?
EMG | Angiotests
54
Common treatments for TOS?
PT, MEDS | Surgical removal of 1st rib
55
What region of the clavicle is most likely to have a fracture?
Middle 1/3 (80%) | Lateral 1/3 (15%)
56
What are some common complications of distal 1/3 clavical fractures?
Usually require orthopedic management May require surgery May result in post traumatic a/c arthritis
57
When is surgery indicated for mid 1/3 clavicle fractures?
With significant displacement, comminution, or spiked fragments/kick-stand fragments with risk of lung injury
58
What are some common complication in all clavicle fractures?
Fibrous Non-union - lays down a lot of bone, but doesnt fully fuse (movement is still seen) Pneumothorax - fragment pierces the pleura Subclavian artery injury
59
What is the usual treatment for a proximal clavicle fracture?
Usually require ortho intervention
60
What type of injury is usually seen along with a fractured scapula?
Pulmonary contusions | Possible Rib Fractures due to the force required to fracture the scapula
61
Which types of scapular fractures generally require surgical innervention?
Glenoid involvement - displacement or intra-articular involvement
62
What does the name Codman have to do with the shoulder/fractures?
Recognized that proximal humeral fractures in adults generally occur along the lines of old physeal scars 1. greater tubercle 2. lesser tubercle 3. humeral head 4. humeral diaphysis
63
Who typically present with proximal humeral fractures?
Old ladies who fall on outstretched hand (osteopenia/porosis)
64
What are the 4 types of proximal humeral fractures described by Neer's?
1 Part - Impacted 2 Part - Greater tuberosity 3 Part - Head separates from shaft at surg. neck and greater tuberosity separates like a 2 part 4 Part - Head, greater, and lesser tuberosity all involved.
65
What is a common complication of a 4 part proximal humerus fracture
AVN
66
Describe treatment for a 1 part proximal humerus fracture?
Non-surgical 1-3 weeks immobile Pendulum and ROM btw 3-8 weeks Elbow ROM
67
Describe treatment for a 2 part proximal humerus fracture. (surgical neck)
surgery
68
Describe treatment for a 2 part proximal humerus fracture. (Greater tuberosity) Lesser?
Surgical ORIF if displacement is greater than 5mm due to the impingement on the acromion usually screw wire suture Lesser - not as common, suture fixation or possibly remove a bone fragment and refix subscap to the fracture site
69
Describe treatment for a 3 part proximal humerus fracture
Very unstable ORIF with wires or suture Use locked plates with osteoporotic bone to ensure fixation
70
Describe treatmetn for a 4 part proximal humerus fracture
Poor results with ORIF, due to high incidence of AVN | Preferred treatment is prosthesis with secure fixation of tuberosities to allow early motion
71
What is the main blood supply to the humeral head?
Anterior circumflex humeral artery off of the axillary artery

Musculoskeletal System (21 decks)

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