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Y2 MSK > Upper limb problems > Flashcards

Upper limb problems Flashcards

1
Q

Shoulder joint type of joint

A

Ball and socket synovial joint

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2
Q

Shoulder joint depends on what factor for stability

A

Surrounding muscles - especially rotator cuff muscles

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3
Q

Shoulder joint is the articulation of

A

Head of humerus with glenoid fossa of the scapula

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4
Q

Importance of the glenoid labrum

A

Deepens the glenoid fossa to allow more stability and shock absorption

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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

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6
Q

What is a joint capsule

A

Fibrous sheath which encloses the structures of the joint

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7
Q

Borders of the joint capsule of the shoulder

A

From anatomical neck of the humerus to the border of the glenoid fossa

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8
Q

What is at the inner surface of the joint capsule of the shoulder

A

Synovial membrane producing synovial fluid
Synovial Bursae

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9
Q

Function of bursae

A

To reduce friction, acting as a cushion between tendons and other joint structures

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10
Q

What are the bursae in the shoulder joint

A

Subscapular bursa
Subcoracoid bursa
Subcacromial bursa
Subdeltoid bursa

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11
Q

Function of the subacromial bursa

A

To protect the supraspinatus from wear between the humeral head and acromion

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12
Q

Function of the subscapular bursa

A

To protect the subscapularis from wear and tear during movement at the shoulder joint

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13
Q

Which shoulder bursa is the most commonly inflamed

A

Subacromial bursa

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14
Q

Name the rotator cuff muscles

A

Subscapularis
Supraspinatus
Infraspinatus
Teres minor

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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

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16
Q

Innervation of supraspiantus

A

suprascapular nerve

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17
Q

Innervation of infraspinatus

A

Suprascapular nerve

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18
Q

Innervation of subscapularis

A

Upper and lower Subscapular nerve

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19
Q

Innervation of teres minor

A

Axillary nerve

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20
Q

Function of the supraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)

A

abduct arm 0-15 degrees

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21
Q

Function of infraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)

A

Laterally rotates the arm

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22
Q

Function of teres minor (except from providing a stable fulcrum for deltoid to abduct arm)

A

Laterally rotates the arm

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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

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24
Q

What are the ligaments of the shoulder joints

A

Glenohumeral ligament
Coracoacromial ligament
Coracohumeral ligament
Transverse humeral ligament

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25
Q

The joint capsule of the shoulder is formed from which ligament

A

Glenohumeral ligament

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26
Q

Function of glenohumeral ligament

A

Main stabilizer of the joint
Prevents anterior dislocation

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27
Q

Function of coracoacromial ligament

A

Prevents superior dislocation of the humeral head
Roof of subacromial space

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28
Q

Function of transverse humeral ligament

A

Holds the tendon of long head of biceps in the inter tubercular groove

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29
Q

Describe how the abduction of the arm is performed

A
  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
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30
Q

Extension of the shoulder is performed by

A

Posterior deltoid
Latissimus dorsi
Teres major

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31
Q

Flexion of the shoulder is performed by

A

pectoralis major
anterior deltoid
coracobrachialis
biceps brachii weakly assists

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32
Q

Adduction of the shoulder is performed by

A

Pectoralis major
Latissimus dorsi
Teres major

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33
Q

Shoulder dislocation is most commonly seen in

A

Sporty younger patients

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34
Q

Most common type of shoulder dislocation

A

Anterior shoulder dislocation - humeral head anterior to glenoid

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35
Q

Mechanism of injury for anterior shoulder dislocation

A

Fall with shoulder in external rotation

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36
Q

complication for anterior shoulder dislocation

A

Damage to axillary nerve
Shoulder instability

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37
Q

Which nerve is most at risk of damage from anterior shoulder dislocation

A

Axillary nerve

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38
Q

What is required to assess axillary nerve injury

A

Regimental badge area sensory assessment

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39
Q

How may shoulder instability occur after shoulder dislocation

A

Due to
- Bankart lesion
- Hillsach lesion

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40
Q

What is Bankart lesion

A

Damage to glenoid labrum

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41
Q

What is Hillsach lesion

A

posterolateral humeral head depression fracture

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42
Q

Injury mechanism of posterior shoulder dislocation

A

Fall with shoulder in anterior location
Direct blow to anterior shoulder

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43
Q

Injury mechanism of inferior shoulder dislocation

A

Shoulder forced into hyperabduction

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44
Q

Why should you do a prompt neuromuscular assessment of a patient with inferior shoulder dislocation

A

Because it is close to the brachial plexus

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45
Q

Symptoms of shoulder dislocation

A

Severe shoulder pain
Inability to move shoulder

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46
Q

Clinical signs of shoulder dislocation

A

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

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47
Q

Investigations for shoulder dislocation

A

Xray - AP and Oblique
MRI arthrogram (if suspect Bankart lesion)
Regimental badge area sensory assessment
Extension lag test

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48
Q

Why should both AP and oblique Xray be used to investigate shoulder dislocation

A

Because posterior dislocation is difficult to see on AP xray

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49
Q

Xray sign of posterior shoulder dislocation

A

Light bulb sign

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50
Q

What is the extension lag test

A

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

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51
Q

Management for shoulder dislocation

A

Analgesia
Closed reduction under sedation / open reduction

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52
Q

Post reduction management for shoulder dislocation

A

Analgesia
Rehabilitation

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53
Q

Recurrent dislocation (shoulder instability) risk is higher in

A

younger patients

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54
Q

What genetic syndromes can cause ligamentous laxity hence atraumatic shoulder instability

A

Ehler Danlos
Marfan’s

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55
Q

Management for traumatic shoulder instability

A

Bankart repair surgery

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56
Q

What tests can be used to check for shoulder instability

A

Posterior and anterior drawer test
Sulcus sign
Posterior and anterior apprehension test

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57
Q

Describe the posterior apprehension test

A
  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
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58
Q

Describe the anterior drawer test

A
  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
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59
Q

Describe the sulcus sign

A
  1. Patient sitting
  2. Grab the patient’s forearm below the elbow and pull it inferiorly
    Positive = depression under the acromion
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60
Q

Shoulder impingement most commonly affects

A

under 25
Sporty

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61
Q

What is shoulder impingement

A

Inflammation of the rotator cuff tendons as they are compressed in the subacromial space during movement

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62
Q

Causes of shoulder impingement

A

Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophyte

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63
Q

Which rotator cuff tendon is the most commonly inflamed in shoulder impingement

A

Supraspinatus

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64
Q

Symptoms of shoulder impingement

A

Pain radiating to deltoid and upper arm
Tenderness at lateral edge of acromion
Difficulty reaching over head

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65
Q

Investigations for shoulder impingement

A

Hawkins Kennedy test
Jobe’s
Xray - AP and oblique

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66
Q

Xray result for shoulder impingement

A

Normal
This helps rule out joint arthritis

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67
Q

Describe the Hawkins Kennedy test

A

Internally rotating the flexed shoulder

68
Q

Describe the Jobe test

A
  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
Q

Management for shoulder impingement

A

Rest
Analgesia
NSAID
Physiotherapy
Subacromial injection of steroid
Surgery if indicated

70
Q

When is subacromial injection of steroids used indicated in shoulder impingement

A

Symptoms does not settle after analgesia / NSAID
Subacromial bursitis

71
Q

How many times can subacromial injection of steroid be used in shoulder impingement

A

3

72
Q

When is surgery indicated in shoulder impingement

A

If after 6 months of conservative management the symptoms continue

73
Q

Tendons of rotator cuff muscles most commonly tear in

A

> 40 years old

74
Q

Tendons of rotator cuff can tear with minimal or no trauma due to

A

Degenerate changes in tendon

75
Q

What is a classic history of rotator cuff tear

A

Sudden jerk (holding a rail on a bus which suddenly stops) in a patient over 40, with subsequent pain and weakness

76
Q

Can rotate cuff tear be asymptomatic

A

Yes, in patients over 60, it can be asymptomatic

77
Q

Which tendon of rotator cuff muscle is the most commonly torn

A

Supraspinatus

78
Q

Extent of tears of rotator cuff muscle can be

A

Partial or full thickness

79
Q

Large tear of rotator cuff muscle can

A

Extend from supraspinatus to subscapularis and infraspinatus

80
Q

Symptoms of rotator cuff tear

A

Can be asymptomatic in elderly
Pain radiating down the arm
Weakness

81
Q

What weaknesses can be seen in rotator cuff tear

A

Initiation of abduction - supraspinatus
Internal rotation - subscapularis
External rotation - infraspinatus

82
Q

Clinical signs of rotator cuff tear

A

Weaknesses
Muscle wasting of supraspinatus

83
Q

Investigations for rotator cuff tear

A

Jobe’s test
Xray
US if good ROM
MRI if reduced ROM

84
Q

Treatment for rotator cuff tear

A

Surgery (controversial)
Physiotherapy
Subacromial injection for symptomatic relief

85
Q

Why is rotator cuff repair surgery controversial

A

Because failure of repair occurs in 1/3 of cases

86
Q

Goal of physiotherapy for rotator cuff tear

A

Strengthen the other muscles to compensate for the loss of supraspinatus

87
Q

complications of rotator cuff tear

A

Torn rotator cuff = deltoid can pull the head of humerus upwards
Abnormal forces on glenoid leads to OA

88
Q

What is adhesive capsulitis (frozen shoulder)

A

Inflammation and fibrosis of the shoulder joint capsule leading to contracture of the shoulder joint

89
Q

Risk factors for adhesive capsulitis

A

40-50
Female
Diabetes
Hypercholesterolaemia
Dupuytren’s disease

90
Q

Stages of adhesive capsulitis

A
  1. Freezing stage - pain
  2. Frozen stage - pain subsides but stiffness increases
  3. Thawing stage - stiffness resides -> recovery of shoulder motion
91
Q

How long does freezing stage last in adhesive capsulitis

A

2-9 months

92
Q

How long is stiffness felt in adhesive capsulitis (frozen stage)

A

4-12 months

93
Q

What is the main clinical sign of adhesive capsulitis

A

Loss of external rotation

94
Q

OA of the shoulder can also cause loss of external rotation. How do you differentiate between OA and adhesive capsulitis

A

OA occurs in much older patients

95
Q

Management of adhesive capsulitis

A

Self limiting
Physiotherapy
Analgesia
Glenohumeral injection can help in painful stage
Manipulation under anaesthetic / surgical capsular release if indicated

96
Q

When is manipulation under anaesthetic / surgical capsular release indicated in adhesive capsulitis

A

If the patient cannot tolerate the functional loss due to stiffness

97
Q

What are the other causes of shoulder pain

A

Inflammation of the tendon of long head of biceps
Tears in glenoid labrum (SLAP lesions)
Referred pain

98
Q

Complication of inflammation of the tendon of long head of biceps

A

Popeye deformity - abnormal shortening of bicep muscles due to rupturing of the inflamed tendon

99
Q

How can tears in glenoid labrum be detected

A

MRI arthrogram

100
Q

What conditions can cause referred pain to the shoulders

A

Neck problems
Diaphragmatic irritation.- biliary colic, hepatic, subphrenic abscess

101
Q

Name A - G of the humerus

A

A - anatomical neck
B - Greater tuberosity
C- Surgical neck
D - Humeral head
E - Intertubercular groove
F - Lesser tuberosity
G - Deltoid tuberosity

102
Q

Name A - F of the shoulder joint

A

A - acromion process
B - articular cartilage of humeral head
C - Humerus
D - Glenoid fossa
E - Scapula
F - Coracoid Process

103
Q

The greater tubercle of humerus is an attachment point for

A

Supraspinatus muscle tendon
Infraspinatus muscle tendon
Teres minor muscle tendon

104
Q

The lesser tubercle of humerus is an attachment point for

A

Subscapularis muscle tendon

105
Q

Name A-G

A

A - supraspinatus muscle
B - greater tuberosity
C - lesser tuberosity
D - Subscapularis muscle
E - Supraspinatus muscle
F - Infraspinatus muscle
G - Teres minor

106
Q

The inter tubercular groove of the humerus is an attachment point for

A

Long head of biceps (runs along the groove)
Pectoralis major
Latissimus dorsi
Teres major

107
Q

Name A-D

A

A- intertubercular groove
B - Pectoralis major
C - teres major
D - Latissimus dorsi

108
Q

Deltoid tuberosity is the attachment point for

A

Deltoid muscle

109
Q

This image is describing the course of

A

Radial nerve

110
Q

Describe the course of radial nerve

A
  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
Q

Radial groove is at the posterior / anterior aspect of humerus

A

Posterior

112
Q

What structures run along the radial groove

A

Radial nerve
Radial artery

113
Q

The borders of cubital fossa

A

Superior - transverse line between medial and lateral epicondyles
Medial - Pronator teres
Lateral - Brachioradialis

114
Q

Name A-C

A

A - Pronator teres
B - Transverse line between medial and lateral epicondyle
C - brachioradialis

115
Q

What muscles attach to the anterior shaft of humerus

A

Coracobrachialis
deltoid
brachialis
brachioradialis

116
Q

Name A-E

A

A - Subscapularis (attached to lesser tubercle not the inter tubercular groove)
B - teres major
C - Coracobrachilais
D - Triceps brachii
E - Brachialis

117
Q

Name this muscle

A

Brachioradialis

118
Q

Attachment point

A
119
Q

Which muscles attach to the posterior aspect of humeral shaft

A

Medial and lateral heads of triceps brachii

120
Q

Name A-E

A

A - Lateral head of triceps
B - Medial head of triceps
C - Long head of triceps
D - triceps tendon
E - Ulna

121
Q

The long head of triceps does not insert onto the posterior humeral shaft. Where does it origin and attach to

A

Originate from infraglenoid tubercle of scapula
Insert onto Posterior surface of the olecranon process of the ulna

122
Q

Name A-G

A

A - olecranon fossa
B - Lateral epicondyle
C - Trochlea
D - medial epicondyle
E - Coronoid fossa
F - Radial fossa
G - capitulum

123
Q

Which nerve passes between the medial epicondyle and olecranon

A

Ulnar nerve

124
Q

Name A-D

A

A- Medial epicondyle
B- Ulnar nerve
C- Olecranon
D- cubital tunnel retinaculum

125
Q

What is biceps tendinopathy

A

Inflammation of long head of biceps tendon

126
Q

Cause of biceps tendinopathy

A

Overuse
Instability
Impingement
Trauma

127
Q

Symptoms of biceps tendinopathy

A

Pain at anterior shoulder radiating to elbow
Pain worse by movements

128
Q

What movements worsen the pain of biceps tendinopathy

A

Shoulder flexion
Forearm supination
Elbow flexion

129
Q

Clinical signs of biceps tendinopathy

A

Tenderness
Pop-eye sign

130
Q

Investigations for biceps tendinopathy

A

US

131
Q

Management for biceps tendinopathy

A

Physiotherapy
Surgical repair (controversial)

132
Q

Why is surgical repair for biceps tendinopathy controversial

A

High risk of neurovascular complication

133
Q

Where does proximal humerus fracture usually occur

A

Surgical neck of humerus

134
Q

Proximal humerus fracture is common in

A

Osteoporotic bone - low energy injury

135
Q

Symptoms of proximal humerus fracture

A

Pain
Swelling
Reduced ROM

136
Q

Signs of Proximal humerus fracture

A

Extensive bruising of chest, arm and forearm
Axillary nerve injury
Radial nerve injury (less common)

137
Q

Which nerve is the most commonly damaged in proximal humeral fracture

A

Axillary nerve

138
Q

Apart from axillary nerve, which other nerve can be damaged by proximal humeral fracture

A

Radial nerve but less common

139
Q

Radial nerve damaged at the axilla region due to proximal humeral fracture / shoulder dislocation can lead to

A

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
Q

Investigations for proximal humerus fracture

A

Xray - AP and lateral
CT
MRI if need to identify rotator cuff injury
Regimental badge area sensory assessment
Extension lag test

141
Q

Management for proximal humeral fracture

A

Collar and cuff
ORIF
replacement

142
Q

Humeral shaft fracture can present as

A

Spiral
Oblique
Transverse
Comminuted

143
Q

What type of fracture does the image show

A

Comminuted fracture

144
Q

What type of fracture does this image show

A

Compound fracture

145
Q

Which nerve is most likely to be damaged by humeral shaft fracture

A

Radial nerve

146
Q

Symptoms of humeral shaft fracture

A

Pain
Extreme weakness

147
Q

Signs of humeral shaft fracture

A

Radial nerve injury
-wrist drop
-reduced sensation in the anatomical snuffbox
-may have weakness in triceps brachii but not paralysis

148
Q

Why does wrist drop occur in radial nerve injury

A

Because the extensor muscles of the posterior forearm -> cannot extend the wrist and fingers

149
Q

Where is the anatomical snuff box

A

triangular depression found on the lateral aspect of the dorsum of the hand

150
Q

investigations for humeral shaft fracture

A

Xray - AP and lateral
Assess radial nerve injury

151
Q

Management of humeral shaft fracture

A

Humeral brace
IM nail
ORIF with plate fixation (rare)

152
Q

IM nail for humeral shaft fracture is indicated in

A

osteoporotic bone

153
Q

Name A to J

A

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
Q

The olecranon is an attachment point for

A

Long head of triceps brachii

155
Q

Coronoid process of ulna is an attachment point for

A

Brachialis

156
Q

Brachialis origin and insertion point

A

Anterior shaft of humerus -> coronoid process of ulna

157
Q

Name A - I

A

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
Q

What is the interosseous border

A

Edge of a bone to which a fibrous membrane is attached so the bone is attached to the adjacent bone

159
Q

Name A - C

A

A - Radial notch of ulna
B - Interosseous membrane
C- Ulnar notch of radius

160
Q

Radial tuberosity is an attachment point for

A

Biceps brachii - short and long head

161
Q

Name the superficial contents of cubital fossa (lateral to medial)
(Really Need Beer To Be At My Nicest)

A

Radial Nerve
Biceps Tendon
Brachial Artery
Median Nerve

162
Q

What are the superficial veins in cubital fossa

A

Medial cubital vein
Cephalic vein
Basilic vein

163
Q

Which other nerve can be seen deep in the cubital fossa

A

Radial nerve

164
Q

What does brachial artery bifurcate into and where

A

Radial and ulnar arteries
Birfurcates at the apex of cubital fossa

165
Q

Name A-H

A

A - Brachial artery
B - Median Nerve
C - Pronator. teres
D - Ulnar artery
E - Biceps tendon
F - Radial Nerve
G - Brachioradialis
H - Radial artery

166
Q

Name A-D

A

A - Bicipital aponeurosis (aponeurosis of biceps brachii)
B - Cephalic vein
C - Basilic vein
D - Median cubital vein

167
Q

Cubital fossa is a common site for

A

venopuncture and siting of peripheral venous cannulas
Due to the superficial veins being easily accessible

Y2 MSK (19 decks)

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