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Flashcards in EF Ombro + Impacto + MR Deck (94):
1

Quais são as estruturas primárias estabilizadoras do movimento do ombro?

The ligamentous constraints are the primary stabilizers at extremes of motion.

2

Qual ligamento é o restritor primário da luxação umeral inferior? Qual outra função essa estrutura possui?

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position.

3

Qual grau de abdução de atuação do ligamento glenoumeral médio para restrição da rotação externa?

The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little efect when the arm is in 90 degrees of abduction.

4

Como funciona o ligamento glenoumeral inferior? Qual banda está tensa em rotação externa? E em rotação interna?

The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type model. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out. With internal rotation, the opposite occurs.

5

Qual a função do ligamento glenoumeral anteroinferior?

The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more.

6

Quais os músculos extrínsecos da articulação do ombro?

The extrinsic muscles primarily control movement of the scapula and include the rhomboids, levator scapulae, trapezius, and serratus anterior.

7

Quais são os músculos intrínsecos que controlam a articulação glenoumeral?

The intrinsic muscles control the glenohumeral joint and include the rotator cuf muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), the deltoid, the pectoralis major, the teres major, the latissimus dorsi, and the biceps brachii.

8

Como a ação muscular atua para estabilizar a articulação glenoumeral?

First, they dynamically position the scapula to place the glenoid opposite the humeral head as the shoulder moves. Rowe compared the relationship to a “ball on a seal’s nose.” As the ball (humerus) moves, the seal (scapula and glenoid) moves to maintain the balanced relationship. Second, while ligaments work in a static fashion to limit translation and rotation, their stifness and torsional rigidity are increased with concomitant muscle activity. Rotator cuf activity and biceps activity have been shown to stifen the capsule and decrease glenohumeral translation. Third, intrinsic and extrinsic muscle groups serve as fine-tuners of motion and power movers by working in “force couples.” The force couples control and direct the force through the joint, contributing to stability.

9

A que distancia da inserção ossea ocorre a fusão dos tendões do supra e infraespinhal?

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection.

10

Em qual região ocorre a fusão do infraespinal e do redondo menor?

The infraspinatus and teres minor fuse near their musculotendinous junctions.

11

Descreva a fusão dos tendões do subescapular e do supraespinal?

The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove. The roof of this sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor. This relationship is relevant to the frequent coexistence of subscapularis tendon tears with lesions of the long head of the biceps.

12

Qual a posição anatomica do ligamento coracoumral?

The coracohumeral ligament is a thick band of ibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons. The ligament is deep to the tendinous insertion of the cuf and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath.

13

Quantas camadas apresentam os tendões do supra e infraespinal?

Histological studies of the supraspinatus and infraspinatus tendons identiied five distinct layers.

14

Quais são as distancias de inserções dos tendões do manguito rotador, em média?

The mean medial-to-lateral insertion widths of the supraspinatus, infraspinatus, teres minor, and subscapularis tendons were 12.7 mm, 13.4 mm, 11.4 mm, and 17.9 mm, respectively. The mean minimal medial-to-lateral insertion width of the entire rotator cuff insertion occurred at the midportion of the supraspinatus and was 14.7 mm.

15

O que é o intervalo rotador? Quais são seus limites? Quais estruturas passam em seu interior?

The rotator interval is defined as the triangular area in the anterior and superior shoulder where no rotator cuff tendons are present. As such, the interval is bounded by the supraspinatus superiorly, the subscapularis inferiorly, and the coracoid medially. The apex of the triangle is marked laterally by the transverse humeral ligament. The coracohumeral ligament, biceps tendon, and superior glenohumeral ligament are found in the rotator interval. The rotator interval is altered in pathological states and has been found to be contracted in patients with adhesive capsulitis and expanded in those with shoulder instability.

16

Qual a posição do arco coracoacromial? Quais estruturas passam por esse arco?

The coracoacromial arch lies superior to the glenohumeral joint and is composed of the coracoid and the anterior acromion, which are spanned by the coracoacromial ligament. The distal clavicle usually is considered to be part of the arch as well. The rotator cuff tendons, the subacromial bursa, the biceps tendon, and the proximal humerus all pass beneath this arch.

17

Qual a função secundária do arco coracoacromial?

The coracoacromial arch also serves as a restraint to superior proximal humeral migration, and its disruption is considered the final step in the cascade of events culminating in anterosuperior escape in advanced degenerative shoulder disorders associated with massive rotator cuff tears. In escape, the humeral head dislocates anteriorly and superiorly with attempted forward elevation of the shoulder. As a result, the humeral head comes to rest in a palpable and visible position in the subcutaneous tissues.

18

Quais são as características da dor do paciente com lesões no ombro?

The pain, usually exacerbated by overhead activities, is worse with active rather than passive motion and may awaken the patient from sleep.

19

Como é realizado o teste de impacto de Neer?

With the patient seated, the examiner raises the afected arm in forced forward elevation while stabilizing the scapula, causing the greater tuberosity to impinge against the acromion. Neer also described the impingement test with the use of a subacromial injection of 10 mL of 1% lidocaine (Xylocaine). Pain caused by impingement usually is significantly reduced or eliminated, but pain caused by other conditions (with the exception perhaps of calciic tendinitis) is not relieved.

20

Como é realizado o teste de Hawkins-Kennedy?

The test is performed by forward flexing the humerus to 90 degrees and forcibly internally rotating the shoulder. This maneuver drives the greater tuberosity farther under the coracoacromial ligament, reproducing the impingement pain.

21

Como é realizado o teste de Jobe? Qual músculo é testado?

Jobe described the “supraspinatus test” in 1983. The test is performed by placing the shoulder in 90 degrees of abduction and 30 degrees of forward flexion and internally rotated so that the thumb is pointing toward the floor. Muscle testing against resistance shows weakness or insuficiency of the supraspinatus owing to a tear or pain associated with rotator cuff impingement.

22

Como é realizado o teste de estresse em rotação interna?

The test is performed with the patient seated and the examiner standing behind the patient. The patient’s arm is positioned in 90 degrees of abduction in the coronal plane and approximately 80 degrees of external rotation. A manual isometric muscle test is performed for external rotation and compared with one for internal rotation in the same position. If a patient with a positive impingement sign has good strength in external rotation and weakness in internal rotation, the test is positive. A positive internal rotation resistance stress test suggests internal impingement, and a negative test (more weakness in external rotation) suggests classic outlet impingement.

23

Como é realizado o teste de Gerber para o subcoracoide?

The Gerber test is designed to identify impingement between the rotator cuf and the coracoid process. It is performed in a manner similar to the Hawkins-Kennedy impingement test. The arm is forward lexed 90 degrees and adducted 10 to 20 degrees across the body to bring the lesser tuberosity into contact with the coracoid. Pain with the maneuver indicates coracoid impingement.

24

Como é realizado o teste de apreensão e recolocação de Jobe?

With the patient supine, the arm is abducted 90 degrees and externally rotated, which produces pain from impingement. Application of a posteriorly directed force to the humeral head, relocating it in the glenoid, does not change the pain in patients with primary impingement but relieves the pain in patients with instability (subluxation) and secondary impingement, who tolerate maximal external rotation with the humeral head maintained in a reduced position.

25

Como é realizado o speed teste? Sua positividade indica quais patologias?

The Speed test is performed by having the patient forward flex the shoulder to 90 degrees with the elbow extended and the forearm supinated. Resistance is applied to the forearm, and a positive result produces pain localized to the bicipital groove. In an arthroscopic analysis that included biceps tendinitis and superior labral anterior and posterior lesions as positive findings.

26

Como é realizado o teste de Yargason?

Yergason described the “supination sign” in 1931. The elbow is lexed to 90 degrees, and the forearm is pronated. he patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.The elbow is flexed to 90 degrees, and the forearm is pronated. he patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.TThe elbow is lexed to 90 degrees, and the forearm is pronated. The patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.

27

Quais são os testes que quando positivos indicam síndrome do impacto com probabilidade >95%? Quando eles são negativos, qual a probabilidade dessa sindrome ocorrer?

If the Hawkins-Kennedy sign, the painful arc sign, and the infraspinatus muscle (Jobe) test all were positive, the likelihood of a patient having an impingement syndrome of some degree was greater than 95%; if these three tests all were negative, the likelihood of impingement syndrome was less than 24%.

28

Como é realizado o teste de lift-off?

In 1991, Gerber and Krushell described the lift-off test for detection of an isolated rupture of the subscapularis tendon. With the patient seated or standing, the arm is internally rotated, and the dorsum of the hand is placed against the lower back. If the patient is unable to lift the dorsum of the hand of the back, the test is positive. Electromyography has confirmed that the subscapularis muscle is maximally active with the hand in the midlumbar position and with resistance applied.

29

Como é realizado o belly press test?

In this test, the patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation. If active internal rotation is strong, the elbow does not drop backward, meaning it remains in front of the trunk. If the strength of the subscapularis is impaired, maximal internal rotation cannot be maintained, the patient feels weakness, and the elbow drops back behind the trunk.

30

Como é realizado o teste de estresse em rotação externa?

he external rotation stress test is intended to test the integrity of the external rotators of the shoulder, specifically the infraspinatus and the teres minor. With the patient’s arms by his or her side in neutral flexion and abduction, the shoulders are externally rotated 45 to 60 degrees. The examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resist. Pain and weakness suggest inflammation or tearing of the infraspinatus or the teres minor or both.

31

Como é realizado o external rotation lag test?

The external rotation lag sign test is designed to test the integrity of the supraspinatus and infraspinatus tendons. The patient is seated with his or her back to the examiner. The elbow is passively flexed to 90 degrees, and the shoulder is held at 20 degrees of elevation and near maximal external rotation (maximal external rotation minus 5 degrees to avoid elastic recoil in the shoulder) by the examiner. The patient is asked to maintain the position of external rotation actively as the examiner releases the wrist, while maintaining support of the arm at the elbow. The sign is positive when a lag, or angular drop, occurs. As with all tests, performance and interpretation are complicated by pathological changes in the passive range of motion.

32

Como é realizado o drop sign?

The drop sign is intended to test the integrity of the infraspinatus. The patient is seated with his or her back to the examiner. The afected arm is held at 90 degrees of elevation in the scapular plane and at almost full external rotation with the elbow flexed at 90 degrees. The patient is asked to maintain this position actively as the examiner releases the wrist while supporting the elbow, which is mainly a function of the infraspinatus. The sign is positive if a lag or “drop” occurs.

33

Como é realizado o internal rotation lag sign?

The internal rotation lag sign test is designed to test the integrity of the subscapularis tendon. The patient is seated with his or her back to the examiner. The afected arm is held by the examiner in almost maximal internal rotation. The elbow is flexed to 90 degrees, and the shoulder is held at 20 degrees of elevation and 20 degrees of extension. The dorsum of the hand is passively lifted away from the lumbar region until almost full internal rotation is reached. The patient is asked to maintain this position actively as the examiner releases the wrist while maintaining support at the elbow. The sign is positive when a lag occurs.

34

Qual a contribuição do labrum para a articulação glenoumeral?

The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the depth of the socket by 50% around the humeral head and increases stability. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the antero-posterior direction. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally.

35

Radiografia com rotação interna do ombro avalia qual lesão? E com rotação externa?

The internal rotation view is useful for detecting Hill-Sachs lesions, and the external rotation view provides a good view of the greater tuberosity and proximal humeral physis in skeletally immature patients.

36

Como é chamada a radiografia em AP verdadeiro do ombro? Qual a sua utilidade?

A true anteroposterior radiograph of the glenohumeral joint (also known as the Grashey view) provides the best evaluation of the articular cartilage of the glenoid and the humeral head.

37

Qual a utilidade da incidência radiografica axilar lateral?

The axillary lateral view has the advantage of showing the anatomy of the glenoid rim, the acromion, the coracoid, and the proximal humerus.

38

Qual incidência radiografica é utilizada para classificar o acromio segundo Morrison e Bigliani?

An outlet view assists in the evaluation of patients with rotator cuff disease. This view is a lateral view of the scapula with the tube angled 10 degrees caudad. On this radiograph, the acromion can be classified into one of three types (flat, curved, or hooked).

39

Qual tamanho do espaço acromioumeral sugere lesão do manguito rotador? E lesão massiva?

Superior migration of the humeral head with narrowing of the acromiohumeral space to less than 7 mm suggests a rotator cuff tear, and a space less than 5 mm suggests a massive tear.

40

Lesões de Hill-Sachs são melhor avaliadas com qual incidência radiológica? E as lesões tipo Bankar ósseo?

A Stryker notch view is helpful to evaluate for Hill-Sachs lesions, and a West Point view is used to evaluate bony Bankart lesions.

41

O que indica o extravasamento de contraste na artrografia da articulação glenoumeral?

Leakage of contrast material into the subacromial and subdeltoid spaces ater injection into the glenohumeral joint indicates a fullthickness tear.

42

Qual melhor ponderação da RNM para avaliar lesões do manguito rotador?

T2

43

Qual músculo do manguito é melhor avaliado no corte coronal da RNM? Qual o sinal de lesão crônica desse músculo?

Coronal oblique MR images assist in evaluating the supraspinatus tendon and muscle, delineating the extent of retraction and the size and quality of the supraspinatus muscle. Fatty replacement of the supraspinatus muscle and the supraspinatus fossa indicates chronic pathology.

44

O que pode ser avaliado no corte sagital da RNM?

The sagittal oblique images show the anterior and posterior extent of supraspinatus tearing and the quality of all of the rotator cuff muscles.

45

O que se avalia nos cortes axiais da RNM?

Axial images are used to show the condition of the biceps tendon and of the subscapularis and infraspinatus tendons and muscles.

46

Quando solicitar RNM para um paciente com síndrome do impacto no ombro?

Patients with an insidious onset of shoulder pain and dysfunction do not require MRI evaluation until appropriate nonoperative treatment has failed. Patients for whom surgery is not a consideration do not need MRI unless there are concerns about another pathological entity, such as an infection or neoplasm.

47

Como Neer definiu a síndrome do impacto?

In 1972, Neer described impingement syndrome characterized by a ridge of proliferative spurs and excrescences on the undersurface of the anterior process of the acromion, apparently caused by repeated impingement of the rotator cuf and the humeral head with traction of the coracoacromial ligament.

48

Qual estrutura anatômica é susceptivel ao impacto na flexão do ombro?

The supraspinatus insertion into the greater tuberosity that passes beneath the coracoacromial arch during forward flexion of the shoulder is susceptible to impingement.

49

Quais são os tipos de impactos da síndrome do impacto?

(1) primary impingement, (2) secondary impingement, (3) subcoracoid impingement, and (4) internal impingement. Primary impingement is subcategorized further into intrinsic and extrinsic types.

50

Quando um impacto primário é considerado intrínseco?

When the structures passing beneath the coracoacromial arch become enlarged resulting in abutment against the arch, the cause of the impingement is considered to be intrinsic. Examples of this condition include thickening of the rotator cuff, calcium deposits within the rotator cuff, and thickening of the subacromial bursa.

51

Quando um impacto primário é considerado extrínseco?

Extrinsic impingement occurs when the space available for the rotator cuff is diminished; examples include subacromial spurring, acromial fracture or pathological os acromiale, osteophytes of the undersurface of the acromioclavicular joint, and exostoses at the greater tuberosity.

52

Qual subtipo de acromio, de acordo com a classificação de Morrison e Bigliani, está mais relacionada à síndrome do impacto?

Tipo III (ganchoso)

53

Qual evento é responsável pela síndrome do impacto secundário?

Secondary impingement occurs when there is instability of the glenohumeral joint allowing translation of the humeral head, typically anteriorly, resulting in contact of the rotator cuff against the coracoacromial arch.

54

Quais são os estágios de desenvolvimento da síndrome do impacto e suas idades típicas de aparecimento?

Stage 1: Edema and Hemorrhage
Typical age of patient: 40 years old
Differential diagnosis: subluxation, acromioclavicular joint arthritis Clinical course: reversible
Treatment: conservative

Stage 2: Fibrosis and Tendinitis
Typical age of patient: 25 to 40 years old
Differential diagnosis: frozen shoulder, calcium deposits
Clinical course: recurrent pain with activity
Treatment: consider bursectomy or division of coracoacromial ligament

Stage 3: Bone Spurs and Tendon Rupture Typical
age of patient: >40 years old
Differential diagnosis: cervical radiculitis, neoplasm
Clinical course: progressive disability
Treatment: anterior or acromioplasty, rotator cuff repair

55

Qual é a forma mais comum de síndrome do impacto subcoracoide?

The iatrogenic form was most common in their series, and it was found in patients who had undergone a Trillat osteotomy of the coracoid for the treatment of anterior instability.

56

Quais são os achados de exame físico na síndrome do impacto subcoracóide?

Physical findings attributed to this condition include tenderness over the coracoid and a positive coracoid impingement test. An injection of lidocaine into the subcoracoid region similar to the Neer impingement test has been used to evaluate patients for coracoid impingement. Relief of pain suggests the diagnosis, but the proximity of multiple structures in the subcoracoid region, including the glenohumeral joint itself, makes the accuracy of these injections questionable.

57

Qual a distancia sugerida na TC para a síndrome do impacto subacromial? Qual o tratamento de escolha para essa síndrome?

CT has been used in the diagnosis of coracoid impingement; a suggested distance of 6.8 mm between the coracoid tip and the closest portion of the proximal humerus indicates impingement. For suspected impingement, open or arthroscopic coracoplasty has been recommended.

58

Qual a posição do braço na síndrome do impacto interno? Em qual região o manguito impacta?

Internal contact of the rotator cuff occurs with the posterosuperior aspect of the glenoid when the arm is abducted, extended, and externally rotated as in the cocked position of the throwing motion.

59

Como guiar o tratamento para pacientes com síndrome do impacto primária extrínseca?

The initial treatment of a patient with tendinopathy caused by classic primary extrinsic impingement is a well-planned and well-executed nonoperative regimen including antiinflammatory medications, one or at most two subacromial cortisone injections, and a physical therapy program focusing on stretching for full shoulder motion and strengthening the rotator cuff. If the patient fails to respond ater 3 to 4 months of conservative therapy, operative intervention may be indicated and should be directed to the specific lesion.

60

Quais são os princípios mais importantes postulados por Neer para a realização da acromioplastia?

Main principles of the original procedure as described by Neer are kept in mind, as follows:
■ Release (but not resection) of the coracoacromial ligament;
■ Removal of the anterior lip and lateral edge of the acromion;
■ Removal of part of the acromion anterior to the anterior border of the clavicle;
■ Removal of the distal 1 to 1.5 cm of clavicle if significant degenerative changes are found;

61

Qual a pior complicação mais comum do tratamento cirúrgico da síndrome do impacto?

The worst common complication is loss of anterior deltoid function, which is caused by either axillary nerve injury or detachment of the deltoid from the acromion.

62

Como é caracterizada a dor na lesão do manguito rotador?

Pain usually is present at night and may be referred to the area of the deltoid insertion.

63

Lesão completa do manguito rotador é compatível com função completa?

Sim

64

Qual a taxa de resolução das lesões do manguito com o tratamento não cirúrgico?

Resolution of symptoms has been reported in 33% to 90% of patients treated nonoperatively, and we recommend nonoperative treatment initially for elderly patients or patients with low activity with suspected rotator cuf tears.

65

Qual o fator prognóstico mais relacionado com o sucesso do tratamento não cirúrgico das lesões do manguito?

The duration of symptoms seems to correlate inversely with the long-term success of nonsurgical management because patients with symptoms for longer than 6 months had poorer outcomes.

66

Após os 66 anos, qual a chance de lesão bilateral do manguito rotador?

The presence of rotator cuff disease has been shown to correlate with age; after the age of 66 years there is a 50% likelihood of bilateral tears.

67

Qual a relação da duração com a severidade da doença?

Duration of symptoms also has been correlated with severity the longer the symptoms, the more extensive the fatty degeneration of the torn rotator cuff muscle (moderate supraspinatus fatty infiltration appeared an average of 3 years ater the onset of symptoms and that severe fatty infiltration appeared at an average of 5 years ater the onset of symptoms).

68

Quais os fatores de bom prognostico no tratamento cirurgico do manguito?

Early operative intervention, when most tears are small and less degeneration of the muscle has occurred, improves outcomes.

69

Como é a classificação de lesão do manguito rotador de espessura total (Cofield)?

Small tear:

70

Como é a classificação de Goutallier para degeneração gordurosa do manguito rotador?

Grau 0: Normal
Grau I: Pequenas estrias de gordura
Grau II: Proporção menor de gordura em relação ao músculo
Grau III: Proporção de gordura e músculo se equivalem
Grau IV: Proporção de gordura maior que de músculo

71

Quais são os tipos de lesões parciais do manguito rotador? Qual a mais comum na poupulação geral? Qual a mais comum em jovens?

Partial-thickness tears may be articular sided, bursal sided, or intratendinous. Among partial-thickness tears, cadaver studies indicate that intratendinous tears are more common than articular-sided or bursal-sided tears, whereas a clinical study found that articular-sided tears constituted 91% of all partial-thickness tears in a popu-lation of young athletes.

72

Como são diferenciados as síndromes de impacto do ombro?

- Primária
- Intrínseca (espessamento das estruturas que passam pelo arco coracoacromial - MR, depósito de cálcio no MR, bursa subacromial)
- Extrínseca (diminuição do espaço subacromial - fratura do acromio, os acromiale, osteofito subacromial, spurring subacromial, exostose da tuberosidade maior)
- Secundária (luxação glenoumeral)
- Subcoracóide
- Iatrogênico (após osteotomia de Trillat para instabilidade anterior)
- Idiopático
- Interno

73

Como é avaliado tomograficamente o impacto subcoracóide?

CT has been used in the diagnosis of coracoid impingement; a suggested distance of 6.8 mm between the coracoid tip and the closest portion of the proximal humerus indicates impingement. For suspected impingement, open or arthroscopic coracoplasty has been recommended.

74

Quais modalidade cirúrgicas para o tratamento da síndrome do impacto?

Arthroscopic or open acromioplasty when indicated is the surgical treatment of choice for impingement syndrome.

75

No tratamento cirúrgico da síndrome do impacto, o que deve ser feito como o ligamento coracoacromial?

Original technical descriptions called for resecting and removing a portion of the coracoacromial ligament to prevent the cut edge from scarring back to the acromion. Our current practice is to release the ligament.

76

Como deve ser manejada a lesão de espessura parcial do MR?

For partial-thickness rotator cuff tears, a nonoperative program that includes activity modification, stretching and strengthening exercises, and antiinflammatory medication is appropriate as initial treatment. Operative management is indicated if conservative management fails. Débridement or repair of partial-thickness rotator cuff tears depends on the degree of the tear and the activity level and age of the patient.

77

O que fazer no tratamento cirurgico de uma lesão parcial do MR com 50%?

If a lesion involves less than 50% of cuff thickness, acromioplasty and débridement are suficient treatment. If a tear is longer or thicker, elliptical excision of the diseased tendon and repair are indicated.

78

Qual o objetivo principal da cirurgia para LMR?

The primary goal of operative management of rotator cuff tears is pain relief, and this is accomplished with predictable results. Improvement of function is a secondary but important consideration.

79

Em quais casos a cirurgia para LRM é apropriada?

Surgery is appropriate for an acute rotator cuff injury in a young patient or in an older patient (60 to 70 years old) with a defined injury who suddenly is unable to rotate the arm externally against resistance.

80

Qual contraindicação para a cirurgia de LMR?

Surgery is contraindicated in patients with rotator cuff tears and concomitant stiffness (secondary to adhesive capsulitis). Any significant preoperative stiffness must be corrected before rotator cuff repair to avoid severe postoperative stiffness.

81

Qual a taxa de reruptura do MR?

Rerupture of the cuff occurs in 20% to 65%.

82

Quais são as vantagens do reparo artroscópico para LMR?

Proposed advantages of arthroscopic repair include access for glenohumeral inspection and treatment of intraarticular lesions, no deltoid detachment, less soft tissue dissection, and smaller incisions.

83

Quais são os 5 fatores que melhoram os resultados do tratamento cirurgico das lesões maciças do MR?

Cordasco and Bigliani identified five factors that improved results of operative treatment of large and massive rotator cuff tears:
1. Adequate subacromial decompression
2. Maintaining the integrity of the deltoid origin
3. Mobilizing torn tendons and performing an interval slide when indicated
4. Repairing tendons to bone
5. Carefully supervising and staging postoperative rehabilitation

84

Como é a técnica não anatomica de McLaughlin para reparo do MR?

McLaughlin described suturing the tendon to a trough in bone at whatever point it could be advanced onto the humeral head. This may be more proximal (approximately 2 cm) through the anterior neck area.

85

Qual o melhor tratamento para lesões maciças do MR em que o reparo anatomico não é viável?

Partial repair has been shown to be superior to débridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuf tears.

86

Como é a técnica de Cofield para transposição do subscapular nas lesões do supraespinhal? Qual complicação pode ocorrer com essa técnica?

Cofield described subscapularis tendon transposition to fill large gaps in the supraspinatus insertion. The flap is created by separating the outer portion of the subscapularis from the inner capsular portion. It is detached from the lesser tuberosity and mobilized superiorly to cover the humeral head. Transposition of the upper portion of the subscapularis tendon can result in anterior instability and weakness of internal rotation.

87

Qual a tecnica preconizada para lesões maciças do subescapular e supraespinhal?

For anterosuperior tears involving the subscapularis and the supraspinatus, transfer of the pectoralis major has been described.

88

Para lesões maciças do supra e infraespinal, qual técnica é preconizada?

For posterosuperior tears involving the infraspinatus and supraspinatus, the latissimus dorsi has been transferred.

89

Qual complicação operatória pode ocorrer no reparo da LMR?

An unsolved complication of rotator cuff surgery involves coracoacromial arch deficiency with anterosuperior cuff tears resulting in subluxation of the humeral head, for which there is no efective treatment. Preservation of the coracoacromial arch is the best method to prevent this complication.

90

Como ocorre a artropatia do MR?

Due to a massive rotator cuff tear, normal humeral head depression of the supraspinatus is lost and the unopposed deltoid pull leads to superior subluxation and shearing forces across the glenoid.

91

Quais são os sinais radiográficos de artropatia do MR?

Sourcil sign (erosion of the inferior acromial surface as the humeral head “articulates” against the undersurface of the acromion), inferior humeral head osteophytes, and loss of glenohumeral joint space.

92

Qual é a contra-indicação para realização da artroplastia total convencional do ombro? Qual método de artroplastia é realizada nesses casos?

LMR irraparável. Artroplastia total reversa.

93

Classificação de Ellman para LMR

1 - Crescent
2 - Reverse L
3 - L shaped
4 - Trapezoidal
5 - Massive tear Full thickness rotator cuff tears

94

A que distancia o nervo subescapular passa medialmente em relação ao colo da glenoide?

1,8 cm