Joints And Fractures - Rush - Msk

Front 1

What are the 4 separate joints of the shoulder?

Back 1

1. Glenohumeral
2. Scapulothoracic (if fuses, lose ROM)
3. Sternoclavicular
4. Acromioclavicular

Front 2

What are the 3 ligaments of the shoulder?

Back 2

1. Coracoacromial
2. Coracoclavicular (traps and coroid)
3. Capsular (attached to bone, holds shoulder in place)

Front 3

***Shoulder Capsule

Back 3

1. Redundant structure that attached to the neck of the scapula
2. Forms a pouch--> synovial recess
3. Lined w/ synovium (produces fluid and synovial lining over biceps)
4. RC tendons envelope the head, incorporate and strength capsule

Front 4

What are the 7 muscles of the shoulder?

Back 4

1-4 = RC muscles = SItS (Supra/infra spinatus, teres minor, sub scapularis)
5. Deltoid
6. Teres major
7. Coracobrachialis

Front 5

***Glenoid labrum

Back 5

-glenoid cavity is surrounded by fibrocartilaginous structure call glenoid labrum
-long head of biceps attaches here
-in labrum tear pt has sens of instability, due to loss of 'suction'

Front 6

Glenohumeral motion vs. Scapulothoracic motion***

Back 6

-occurs in a 2:1 ratio
-for every 30 degrees of elevation, there are 20 degrees of glenohumeral motion and 10 degress of scapulothoracic motion

Front 7

What happens to pts w/ severe glenohumeral diseases such as arthritis?

Back 7

-still movement due to scapulothoracic
-use "shrugging mech" to elevate arm
-use accessory muscles to lift arm
-RC tears
-pts dev neck muscle pain due to use

Front 8

What are the 2 things that the RC must do to abduct the arm?

Back 8

1. Fix humeral head in glenoid
2. Cause the head to descend - if this descending mechanism isn't working imping due to supraspinatus rubbing against the acromium

Front 9

What are the 2 muscles aid in depressing upper end of the arm during abduction?

Back 9

1. Lat dorsi
2. Pec major

Front 10

What are important aspects of inspection of the shoulder when pt comes into the office?

Back 10

1. Both shoulders (BILAT)
2. atropy, swelling, ecchymosis, cellulitis, induration
3. Take not of deformities like bumps or scars (previous injuries)

Front 11

Speed's test

Back 11

-for biceps, try to activate biceps by flexion motion
-if biceps are the problem, there will be pain during this manuever

Front 12

Sulcus sign

Back 12

-pulling down shoulder to see if humeral head slides out of glenoid
-dislocation will show positive
-Ehlers-Danlos syndrome, high risk of dislocation

Front 13

Impingement Sign

Back 13

-problem in the subacromial area
-painful arc btwn 45-120 degrees
-internally rotated arm into abduction against the acromion

Front 14

Drop arm test

Back 14

-hold 90 deg abducted, push arm down
-if large RC tear, pt will drop arm
-if only 1 RC pt may or may not drop

Front 15

Empty can test

Back 15

-abduct arm 90 deg w/ thumb down
-cause sig pain in a supraspinutus tear pt

Front 16

Adson's maneuver

Back 16

-tests for vascular compression by bringing the arm into abduction and rotating head way to see if there's a decreas in pulse

Front 17

RC Tears

Back 17

-almost all ppl over 60 will have partial
-tendons rub btwn humeral head and coracoacromial arch
-MC torn is supraspinatus

Front 18

RC Exam***

Back 18

a. Tender over the supraspinous tendon attach at greater tuberosity
b. if tear is small and incomplete, ROM may be complete and may or may not have a pos drop arm test
c. large tear, abduction is weak, small ROM

Front 19

RC diagnosis

Back 19

-Hx and PE are key to diagnosis
-X-ray helpful to rule out things such as tumors or arthritis

Front 20

***Goals of treatment

Back 20

1. Restoration of comfort
2. Restoration of fxn
3. Prevention of reoccurence or progression of tears

Front 21

***Calcific tendonitis

Back 21

-MC is in supraspinatus
-etiology unknown, F>M, 30-50 y/o
-Dx by X-ray
-when calcium is resorbed is when pt will feel pain (usually lat aspect of shoulder)

Front 22

***How do you distinguish calcium deposition in a tendon from an avulsion fracture?

Back 22

-Ca deposit will be a well rounded fragment which demonstrates that its been there a while
-rare for avulsion fracture to go untreated for that long

Front 23

***Biceps Tendonitis

Back 23

-generally secondary to an inflammatory process within the shoulder
-as tendon ages, it is subjected to wear and tear and can rupture

Front 24

***What are the 2 types of bicep lesions?

Back 24

1. Imingement tendonitis - MC
-in conjunct w/ imping and RC tears
-biceps rubs btwn head and CA lig
2. Attritional tear
-primary bicipital tendonitis, intense synovial rxn, edema, swelling but intraarticular area ok
***MCC of complete rupture

Front 25

***What are some major findings for diagnosis and for examination?

Back 25

-[+] speed test, pain less intense w/ rest
-Xray is normal
-point tender at bicep groove
-"Popeye looking muscle"

Front 26

***Frozen Shoulder (Adhesive Capsulitis)

Back 26

-the pt has a restricted active and passive glenohumeral ROM for which no other cause can be identified
-may be overlap of symptoms and can coexist w/ other shoulder pathologies

Front 27

***Frozen Shoulder (Adhesive Capsulitis)

Facts continued...

Back 27

-pain/inflamm--> less movement of arm which leads to formation of adhesions w/in the capsule and decreased ROM
-F>M, Right arm> Left arm, >40 y/o

Front 28

What are the 2 phases of Frozen Shoulder?

Back 28

1. Painful phase --> diffuse shoulder pain lasting weeks to months (worse at night, and exacerbated by lying on side)
2. Stiffening phase--> slow progressive loss of ROM w/ adhesions forming

Front 29

AC joint separation

Back 29

-injury to AC joint by either a direct blow to shoulder or by fall onto tip of shoulder
-w/ fall 3 things can happen: AC injury, break clavicle, or dislocate shoulder

Front 30

***Grade 1

Back 30

-minimal to mild tenderness and swelling over AC joint (partial tearing of AC lig)
-mild loss of motion due to pain
-tx: non op, sling for comfort

Front 31

Grade 2:

AC sublaxation

Back 31

-moderate to severe pain at AC joint
-distal end of clavicle can be "rocked"
-tenderness in the coracoclavicular interspace
-tx same as grade 1

Front 32

Grade 3: AC dislocation

Back 32

-arm held in adducted and supported in an elevated position
-clavicle is high riding and may tent the skin
-pain at AC interspace, clavicle can be depressed like a piano key
-stress films are positive

Front 33

Grade 3 Tx

Back 33

-controversial
1. usually sling and strapping to open reduction
2. Functional results long term are the same

Front 34

Grade 4: Posterior subluxation of the clavicle (clavicle pulled backwards)

Back 34

-Very rare
-more painful at AC interspace
-viewed from above there is a posterior inclination of clavicles

Front 35

Grade 5: Exaggeration of type 3

Back 35

-distal end of clavicle appears grossly displaced superiorly
-pain at AC interspace
-greater tissue disruption

Front 36

Grade 5 Tx

Back 36

-may try closed reduction, may require surgery to reduce and repair (position of clavicle can cause resp problems)
-limit activity for 2 weeks then use arms for ADLs
-no lifing, pulling, pushing for 8 wks
-if screw in surg, remove after 8 wks

Front 37

Grade 6: Inferior dislocation

Back 37

-extremely rare
-a/w severe trauma and usually has rib fracture and/or brachial plexus injury
-very painful - always surgical

Front 38

Glenohumeral dislocation

Back 38

-***50% of all dislocations b/c shoulder has such high ROM

Front 39

Types of GH dislocations***

Back 39

1. Anterior inferior/medial - MC
-subglenoid or sub coracoid - MC
2. Subclavicular
3. Intrathoracic
4. Posterior (not common)

Front 40

Xrays for GH dislocations

Back 40

1. AP view
2. Scapular Y - rotates shoulder 30 degrees, one of most accurate views for GH dislocation
3. Transthoracis view - lift arm on one side and shoot xray thru chest

Front 41

***What are the most important aspects of treatments of dislocations?

Back 41

1. Reduction (pull out/away joint, then down away from joint)
2. protection and muscle rehab
3. Immob 2-5 weeks - get shoulder moving ASAP
4. PT

Front 42

***What is the MC injured nerve during reduction?

Back 42

-Axillary nerve

Front 43

***What is Chondrocalcinosis

Back 43

-calcification of meniscus
-MC from degen and trauma
-seen w/ pseudogout
-sx not form calc, bu original cause of pain
-CAN see outline of meniscus on Xray making dx easy

Front 44

***Baker's cyst

Back 44

-Popliteal cyst
-enlargment of semimembranous bursa
-in children its primary, tx cyst
-adults it is secondary to intraarticular pathology

Front 45

***Baker's cyst:

PE, Dx, Tx

Back 45

-fullness and possibly pain in popliteal space
-dx: based on PE b/c xray and MRI usually nL
-children --> tx the bursa
-adults --> tx underlying pathology

Front 46

****Osgood-Schlatter Disease:

Back 46

-disorder of tibial tuberosity (traction epiplysitis aka apophysitis)
-occurs in adolescents (females 10-12, males 12-14)

Front 47

****Osgood-Schlatter Disease:

Sx

Back 47

1. pain w/ inc activity, decreases w/ rest
2. Anterior knee swelling
3. Decreased motion of knee
4. No pain w/ weight bearing

Front 48

****Osgood-Schlatter Disease:

PE

Back 48

1. pain on palpation, swelling
2. NO ligamentous laxity (bc doesn't involve joint itself)
3. Inc pain w/ extension against resistance

Front 49

****Osgood-Schlatter Disease:

X-Ray

Back 49

-shows two findings:
1. lateral shows fragmentation of tuberosity
2. Elevation of tuberosity

Front 50

****Osgood-Schlatter Disease:

Tx

Back 50

1. Decreased activity - to decrease swelling
2. NSAIDs
3. Ice and bracing
4. Disease is self limiting as tuberosity fuses w/ age

Front 51

***Prepatellar Bursitis
(AKA House Maid's Knee)

Back 51

-occurs btwn skin and patella
-irritated w/ repeated trauma
-can get infx
-Tx: avoid irritating activity (kneeling)
-aspiration, injection, surgery