Shoulder Flashcards
What kind of xray view do you use for AC jt and bony bankart fractures?
Westpoint-
- view
-patient must be prone, arm out to side hanging over table
-modified axial projection
-can see the anterior glenoid
Best Treatment for faster Return to play for mid shaft clavicle fractures
Open reduction and plate fixation
can return 10-12 weeks
What is a possible complication of clavicle injury and what are the signs?
Subclavian artery injury
-N/T in ipsilateral hand
-no motor weakness in UE’s
Which ligaments are primary restraints of posterrior and inferior instability
-Superior glenohumeral ligament
-Coracohumeral ligament have been shown to provide resistance to posterior and inferior instability. This occurs best in humeral ADD and ER
Which ligaments restrains anterior instability When shoulder at 45°,
the middle glenohumeral ligament
What happens in the shoulder joint ligaments When abduction increases to 90°,
the anterior band of the inferior glenohumeral ligament restrains against anterior instability
4 Types of SLAP TEARS
- Type 1: labral fraying
Type 2: biceps torn off- peel back
Type 3: bucket handle tear
Type 4: biceps split
Describe Type 2 SLAP tear
-detached biceps tendon
- during late cocking
- biceps tendon gets twisted and peels labrum and bicep from glenoid,
-can cause ant or post dislocation
Describe type 3 SLAP
Bucket handle tear
- labrum hangs into joint causing locking and popping
Describe Type 4 SLAP
-Bucket handle tear that SPLITS BICEPS TENDON
-can also cause locking and popping
The Lateral Scapular Slide Test (LSST)
to determine scapular position with the arm abducted 0, 45, and 90 degrees in the coronal plane. Assessment of scapular position is based on the derived difference measurement of bilateral scapular distances.” Patients with suspected scapular weakness have increased measurement values on the involved side. Now, that being said, it isn’t a stellar test. Furthermore, the results suggest that sensitivity and specificity of the LSST measurements are poor and that the LSST should not be used to identify people with and without shoulder dysfunction.” However, you may still see it on your exam.
Secondary shoulder impingement
relative impingement occurring in the presence of rotator cuff weakness or instability of the capsule
describe injury to Suprascapular Nerve
innervates supraspinatus and infraspinatus, will see infraspintaus atrophy, can be compressed in the suprascapular notch or spinoglenoid notch
What is most commonly injuried nerve after shoulder dislocation
Axillary
-innervates deltoid, teres minor and long head of triceps
sensory distribution covers shoulder joint- regimental badge
What does a (-) negative LR of 0.92 show?
is weak and is not enough information to definitively rule out the condition.
a neg LR (-) of .92 is weak and is not enough information to definitively rule out the condition. -LR should be close to zero
Symptoms of anterior instability
-Feeling shoulder will dislocate when in throwing position
-Shoulder abducted and externally rotated
What percentage of dislocations reccur in less than 20 year olds?
Dislocation has been reported to recur in 66% to 100% of people aged 20 years or under
What percentage of shoulder dislocations occur in people aged between 20 and 40 years?
13% to 63%
Are you at large risk of shoulder dislocation if you are over 40?
No- 0-16%
What are signs of inferior instability:
paresthesia when carrying a heavy object at their side
symptoms of posterior instability
Symptoms when pushing a heavy door or performing pushups
Describe a Putti Platt surgery
Putti-Platt -will stabilize with a soft tissue restriction rather than a bony block allowing for less pain and degeneration,
This procedure divides the subscapularis tendon, overlaps it, and repositions it to achieve anterior capsular stability.
This is not performed in throwers due to the risk for range of motion loss. While this material was not covered in your weekly material, you will see a
Benefit of a bankart repair
Bankart repair can prevent anterior head translation during cocking phase of throwing
What happens to the shoulder during The cocking phase
– the torsional peel back force occurs on the biceps labral complex
-Accleration phase leads to more medial elbow injuries
Best treatment for traumatic anterior shoulder instability -dislocation
Surgery
Traumatic anterior shoulder instability rarely (<20%) can be successfully rehabilitated without surgery, there is a high incidence of recurrence.
A neuropraxia
- ‘class I’ or ‘transient’ or ‘delayed reversible’) type of nerve injury -usually only persists for several weeks.
-Weakness in shoulder ABD and ER
-decreased sensation over the lateral side of the proximal part of the arm. –The patient may have already recovered full neurological function at 4 weeks.
Axillary nerve injury is the most common nerve injury after anterior shoulder dislocation.
The Axillary nerve winds around the surgical neck of the humerus after passing to the posterior aspect of the arm through the quadrangular space. A traction injury can occur with a traumatic anterior dislocation. (about 30% experience mostly mild neuropraxic lesions with less than 5% experiencing significant damage.
Which of the following is commonly seen in collegiate and professional baseball pitchers after pitching for several innings?
Decreased passive IR of the throwing shoulder
The total arc of motion tends to decrease by ~10-11 degrees during a game, but increases throughout the season.
Quebec Decision Rule on sending for possible shoulder dislocation
1.. Aged 40 years or older AND humeral ecchymosis,
2. Aged 40 years or older AND first episode of dislocation, or
3. Younger than 40 years AND injury mechanism other than a fall from standing height or an atraumatic injury.
Average RTS after a type II SLAP lesion repair
12 months
What is a complication of SLAP repair?
suture anchor tips and their relative drilling site can lie very close to the suprascapular nerve and cause an iatrogenic injury
. If the patient experienced atrophy, she will have increased difficulty with scapular stabilization, especially overhead.
after SLAP repair and during rehab When progressing her into an interval hitting program, which serve or attack would you limit at first in an effort to prevent further injury
Jump Serve
Jump serves produce the most IR torque at the shoulder (40 N⋅m). The spike (either cross-body or straight ahead) is slightly less at 37 N⋅m. The float serve generates 31 N⋅m of torque. The roll shot produces only 16 N⋅m.
The running theory that contributes to an overhead athlete developing a SLAP lesion is
The peel-back mechanism describes a potential rationale for SLAP lesions in the throwing shoulder.
Burkhart et al. have hypothesized a peel-back mechanism that produces SLAP lesion in the overhead athlete. They suggest that when the shoulder is placed in a position of abduction and maximal external rotation, the rotation produces a twist at the base of the biceps, transmitting torsional force to the anchor.
Pradhan et al. (AJSM 2001) showed that the increased strain in the late cocking phase may contribute to the detachment of the labrum with the eccentric contraction of the biceps muscle that occurs with rapid extension of the elbow
Sprengel deformity
-relatively rare condition consisting of an elevated, dysplastic scapula that causes cosmetic deformity and restriction of shoulder range of motion
-Congenital elevation of the scapula is caused by an interruption in the normal caudal migration of the scapula.
-Because of the limited scapula motions and the new muscular attachments, AROM is severely limited.
-This congenital malformation probably occurs between the 9th and 12th weeks of gestation. Associated malformations are almost always present with a Sprengel deformity. These can include anomalies in the cervicothoracic vertebrae or the thoracic rib cage. The most common anomalies are absent or fused ribs, chest-wall asymmetry, Klippel-Feil Syndrome, cervical ribs, congenital scoliosis, and cervical spina bifida.
What is the best image for labral lesions?
Due to its superior diagnostic accuracy, MRA is the appropriate imaging modality for labral lesions.
Bankart Lesion
tear of anterior/inferior labrum
Bony Bankart
ant/inf labral tear and fracture of ant/inf glenoid fossa
Hill Sachs Lesion
fracture (cortical depression) of posterior head of humerus
Laterjet Procedure
1.transposition coracoid process to ant/inf glenoid fossa rim for greater congruency during ROM
2. conjoin tendons of shorthead of biceps brachii and coracobrachialis to subscapularis to create sling and reinforce anterior capsule
3. repair the anterior joint capsule unsing coracoid ligament
What organ can refer to the shoulder and what is the Sign called?
Spleen; Kehr’s sign
Pitching Risks in youth
3 x risk if pitch >100 innings per year
4 x if avg > 80 pitches/ game
5x if pitch > 8 months of the year
What does a slap repair entail?
SLAP repair a tear of the biceps tendon at the point where it connects to the labrum, a ring of cartilage that surrounds the shoulder socket
-drills a small hole into the glenoid bone where the labrum has torn away. A tiny anchor tied to a suture is implanted in the glenoid bone. Some tears may be repaired with just one anchor, others require multiple anchors.
- ties the sutures around the torn labrum, reattaching it firmly to the glenoid. If the tendon cannot be repaired, it is released.
During what phase of pitching do rhomboids have high level of EMG activity ?
Acceleration Phase
- so must have good scap retraction in throwers
How much force in shoulder during Late cocking/acceleration phase?
400 N shear force posteriorly
300 N shear force inferiorly
What happens in late cocking/acceleration phase of pitching?
- ant shear force of 400N thru shoulder
-Max ER ROM
-for the above- need contraction of RTC
-rapid IR in acceleration 7000dg/second
-valgus load to elbow- compression at lateral joint, shear at medial joint UCL
What happens in the deceleration phase of pitching?
-most violent phase
-400 N shear force posteriorly shoulder
-300 N shear force inferiorly shoulder
-Max contraction of RTC -most vulnerable
What are characteristics of Normal Throwers Shoulder?
generalized GHjt laxity
-61% pitchers and 47% fielders have + sulcus sign
Ideal isokinetc strength ratio ER/IR 65-75%
-Incr ER ROM- 118-141dgr pitchers, position players 108 dgr avg
-Decr IR ROM- pitchers ~ 62 degr
-Need total ARC Of Motion to be 180 and equal to other side
Acquired anterior instability
- different than Subacromial
-inc stress on anterior structures
-pinch of undersurface of RTC and ant/sup labrum at late cock/early acc
-Test with relocation test
suprascapular N
innervates:
-supraspinatus
-infraspinatus
-subscapularis
-teres major
comes from C4-6
axillary N
innervates deltoid and teres minor
What is a stinger?
sports-related injury of the brachial plexus
-a painful burning sensation that radiates from the neck down the arm - often accompanied by weakness or numbness of the affected area
-usually short term
What is fowler’s Sign
Jobe relocation test - tests for anterior instabiilty
What muscles dynamically resist excessive anterior shoulder translation?
Infraspinatus and teres minor
They actively resist anterior translation
What is the best intervention for pitcher who has severe winging 2/2 long thoracic napraxia?
Napraxia is short term
-Plank with end of range protractions
-elevated as necessary
arcade of struthers
fibrous canal consisting of the medial head of the triceps brachii muscle and its aponeurotic expansion, which extended into the intermuscular septum
Soreness Rules
