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43 Cards in this Set
- Front
- Back
The superior glenohumeral ligament is under the greatest stress when the humeral head and arm are in which of the following positions?
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Inferiorly translated with the arm in 5 degrees of adduction
the superior glenohumeral ligament provides the most restraint to the shoulder joint when the arm--> 0 degrees of abduction or in adduction and pulled inferiorly. |
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What structure provides dynamic glenohumeral stability by compressing the humeral head against the glenoid?
-which glenohumeral ligaments are static stabilizers to resist translation in what direction ? what effect does the teres major and deltoid have on glenohumeral joint? |
Rotator cuff muscles
The rotator cuff is the main DYNAMIC stabilizer of the glenohumeral joint. It functions most at midrange motion, not at the extremes of range of motion. -superior glenohumeral ligament, STATIC stabilizer,--> resists inferior translation at 0° degrees of abduction. -middle glenohumeral ligament, STATIC stabilizer, -->resists anterior translation in the midrange of abduction (~45°) in ER. - teres major adducts and medially rotates arm and is not a significant stabilizer of the glenohumeral joint. -The deltoid muscle primarily abducts the arm and is not the major stabilizer of the glenohumeral joint. |
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Besides the biceps tendon, which of the following structures also pass through the rotator interval?
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The coracohumeral and superior glenohumeral ligaments
Contents of RI = long head of biceps tendon, superior glenohumeral ligament, glenohumeral capsule, and the coracohumeral ligament |
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Which of the following is a primary restraint of anterior and posterior humeral translation at the position of a patient's right shoulder as shown in Figure A?
what do the other 4 ligaments do? |
-The MGHL restrains anterior and posterior translation in the midrange of abduction.
-The CHL (coracohumeral) limits inferior translation and external rotation when then arm is adducted and limits posterior translation when the arm is flexed, adducted, and internal rotation. -The SGHL also restrains inferior translation and external rotation of the adducted shoulder. -The IGHL has an anterior band that is the primary restraint to anterior translation at 90 degrees of shoulder abduction. It also has a posterior band to limit posterior translation. -The CA ligament prevents superior head migration in rotator cuff deficient shoulders. |
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Which of the following is considered the primary static restraint to anterior gleno-humeral translation with the arm in 90 degrees of abduction?
the other star stabilizers, type of stabilizer? |
Inferior gleno-humeral ligament complex
The rotator cuff is a dynamic stabilizer -the capsulolabral tissues are considered static stabilizers. -With the arm at 90 degrees abduction, the anterior band of the inferior gleno-humeral ligament complex is the primary static stabilizer to anterior translation. -The middle (MGHL) resists anterior translation at 45 degrees of abduction. -The superior (SGHL) resists inferior translation with the arm at one's side. |
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Lesions associated with Posterior Instability
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vulsion of posterior band of IGHL Associated with acute subluxations
Posterior Bankart lesions Characterized by detachment of posterior inferior capsulolabral complex Reverse Hill-Sachs lesions Associated with nonreducible and difficult to reduce dislocations Posterior labral cyst Associated with chronic reverse Bankart lesion Posterior glenoid rim fracture Associated with chronic reverse Bankart lesion Lesser tuberosity fracture Associated with posterior dislocation Large capsular pouch Can see with MRI with contrast |
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Physical exam
inspection prominent posterior shoulder and coracoid motion limited external rotation shoulder locked in an internally rotated position common in undiagnosed posterior dislocations provocative tests |
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Radiographs
recommended views AP unreliable may show a 'lightbulb' sign axillary lateral best view to demonstrate a dislocation optional Velpeau view if patient is unable to abduct arm for axillary view |
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CT
indications analyze the extent and location of bone loss in a chronic dislocation (>2 to 3 weeks) MRI indications evaluate for suspected associated rotator cuff tear |
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Operative
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Which of the following patients may benefit from a lesser tuberosity transfer (modified McLaughlin procedure)?
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A young man with a locked posterior dislocation following an electrocution injury at work
Forceful posterior glenohumeral dislocations such as those resulting from seizures or electrocution may sustain a large reverse Hill-Sachs defect resulting in persistent instability in internal rotation or a locked posterior dislocation. |
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A 26-year-old football offensive lineman presents with shoulder pain which is affecting his ability to block effectively. On exam, he has a positive jerk test and a positive Kim test. What is his most likely diagnosis?
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Posterior labral tear
The posterior jerk test is a sensitive exam for ascertaining the presence of posterior glenoid labral tears in the mid-range of the glenoid. The Kim test is more sensitive for posterior-inferior labral tears. he test is positive when pain is present. When the jerk test and Kim test are combined, there is 97% sensitivity in detecting a posterior labral tear. |
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SLAP=superior labrum anterior-posterior; ALPSA=anterior labral periosteal sleeve avulsion; PASTA=partial articular-sided supraspinatus tendon avulsion.
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An acute posterior shoulder dislocation should be suspected in a patient with pain and the shoulder locked in what position?
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They present with the shoulder locked in internal rotation and adduction and lack external rotation. Orthogonal radiographs (anterior-posterior and axillary lateral) are absolutely necessary for proper diagnosis. Patients with posterior shoulder dislocations are often overlooked.
Posterior dislocation patients often have reverse Bankart and reverse Hill-Sachs lesions. |
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A football player subluxes his shoulder while blocking with his arm forward flexed and internally rotated. The “Jerk” test is positive. What is his most likely pathology?
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Kim lesion
This football player likely suffered a posterior inferior labral tear, also known as a Kim lesion, or a Reverse Bankart lesion. The Jerk test is where a posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. A Hill-Sachs lesion is a bony humeral impaction lesion from an anterior dislocation, glenohumeral internal rotation deficit (GIRD) is found in thowers who have a tight posterior-inferior capsule and lack internal rotation, an acromioclavicular separation has pain over the AC joint and may have a positive piano key sign when the clavicle “pops” up with arm depression. |
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Posterior gleno-humeral dislocations are as common as anterior dislocations in which of the following patient groups?
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Epilepsy patients
posterior shoulder dislocations, which are rare clinical entities that occur during seizures and electrocution (due to tetantic muscle contraction) or as a result of high energy trauma. poor prognostic factors associated with posterior shoulder dislocation include late diagnosis, large bony defect of humeral head, associated proximal humerus fracture, and need for arthroplasty. |
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A 35-year-old man awoke following a night of heavy drinking with severe right shoulder pain and inability to raise his arm above his head. A radiograph from the emergency room is provided in Figure A. He was treated with a sling for a diagnosis of rotator cuff tear. Six weeks later, he complains of continued pain and difficulty using the arm. Which of the following is the next best step in management?
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Axillary radiograph of the shoulder
The radiograph demonstrates overlap of the humeral head and glenoid suggesting shoulder dislocation. An Axillary radiograph is necessary to evaluate concentric reduction vs. dislocation of the shoulder. Richardson found apical oblique(axillary) radiographs to be more sensitive than trans-scapular radiographs for identifying posterior shoulder dislocations. |
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A football linemen has posterior shoulder pain after making a block with his arm in forward flexion and internal rotation. What is the most likely diagnosis?
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Posterior labral tear
A football linemen has posterior shoulder pain after making a block with his arm in forward flexion and internal rotation. What is the most likely diagnosis? |
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A 63-year-old diabetic female complains of left shoulder pain and decreased range of motion 7 months after a fall onto her left side. On physical examination she has marked decrease in external rotation. A radiograph obtained earlier that day at her primary care office is displayed in Figure A. What is the next step in management?
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Further radiographic studies are required including an axillary view. The humeral head resembles a "light bulb", indicating a possible posterior shoulder dislocation. Illustration A is an axillary view of this patient confirming chronic two-part fracture-dislocation of the anatomical neck of the humerus.
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A 25-year old female with a seizure disorder complains of persistent left shoulder pain after sustaining a seizure 1 week ago. She was placed in a sling in the ER and is following up in your office. Figure A shows the xray taken in the ER. On examination, her range of motion is limited and is only able to externally rotate to neutral. What is the next test to order?
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Axillary lateral radiograph
Trauma shoulder radiographs (which include an AP, axillary, and scapular Y view) must be obtained in all suspected shoulder dislocations. Posterior dislocations are more common following a seizure. The posteriorly dislocated shoulder is typically held in IR and most consistent finding is a mechanical block to ER caused by the anterior humeral head defect on the posterior aspect of the glenoid. |
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motion
limited external rotation shoulder locked in an internally rotated position common in undiagnosed posterior dislocations |
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A 26-year-old long distance runner presents with insidious onset of hip and groin pain. An MRI of her hip is shown in Figure A. Work-up should include evaluation for which of the following conditions?
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The "female athlete triad" consists of disordered eating, secondary amenorrhea, and osteoporosis (which often manifests as a stress fracture). Treatment includes a multidisciplinary approach including psychological counseling, dietary management, training modifications, calcium and vitamin D supplements, and possibly oral contraceptive pills.
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The "female athlete triad" consists of disordered eating, secondary amenorrhea, and osteoporosis (which often manifests as a stress fracture). Treatment includes a multidisciplinary approach including psychological counseling, dietary management, training modifications, calcium and vitamin D supplements, and possibly oral contraceptive pills.
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a low BMI, and secondary amenorrhea. Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete.
Poor caloric intake Secondary amenorrhea is defined as the cessation of menses for 6 months after at least one normal cycle. The "female triad" includes amenorrhea, disordered eating, and osteoporosis (which may result in stress fractures |
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A 16-year-old gymnast is diagnosed with the female athletic triad. Which of the following treatments is the least appropriate management?
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The female athlete triad consists of eating disorders, amenorrhea, and osteoporosis. Treatment should consist of:
1. Consultation with a psychiatrist or psychologist for counseling to deal with self esteem issues and eating disorders. 2. Training should be limited until menses resume. 3. Supplemental vitamin D and calcium should be initiated as well as consideration of oral contraceptive pills. |
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The female athlete triad consists of eating disorders, amenorrhea, and osteoporosis. Treatment should consist of:
1. Consultation with a psychiatrist or psychologist for counseling to deal with self esteem issues and eating disorders. 2. Training should be limited until menses resume. 3. Supplemental vitamin D and calcium should be initiated as well as consideration of oral contraceptive pills. |
Eating disorder
The female athlete triad refers to the combination of disordered eating, amenorrhea and osteoporosis. The female athlete triad refers to the combination of disordered eating, amenorrhea and osteoporosis. |
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Origin Anterior surfaces and lower borders of transverse processes of L1 - L5 and bodies and discs of T12 - L5
Insertion Lesser trochanter Action Flex the torso and thigh with respect to each other Innervation Direct fibers of L1 - L3 of lumbar plexus (L1, L2, L3) Arterial Supply Lumbar branch of iliopsoas branch of internal iliac artery |
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Origin Lateral margin of obturator ring above ischial tuberosity
Insertion Quadrate tubercle and adjacent bone of intertrochanteric crest of proximal posterior femur Action Rotates the hip laterally; also helps adduct the hip Innervation Quadratus femoris branch of nerve to the quadratus femoris and inferior gemellus (L5, S1) (L5, S1) Arterial Supply Medial circumflex femoral artery, inferior gluteal artery, 1st - 4th perforating arteries, obturator artery, and some superior muscular branches of popliteal artery |
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Where is the origin of the muscle located between the anterior acetabulum and iliac vessels?
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The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the level of the pelvic brim, but could be as close as 4mm in children. The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the level of the pelvic brim, but could be as close as 4mm in children.
The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the level of the pelvic brim, but could be as close as 4mm in children. |
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The medial femoral circumflex artery and first perforating branch of the profunda femoris artery anastamose at which of the following locations?
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Medial to the gluteus maximus insertion
The medial femoral circumflex artery is the primary blood supplier to the adult femoral head. This artery anastamoses with the first perforating branch of the profunda femoris just medial to the gluteus maximus insertion |
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A 57-year-old female with degenerative hip arthritis has questions regarding mini-incision total hip arthroplasty (THA) with comparison to traditional THA. Which of the following statements is true regarding the mini-incision technique?
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No significant difference in hip function at 1 year
Mini-incision THA has not been shown to have any clinical benefit in terms of hip function at long term followup. |
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Figure A is a cadaver specimen where a posterior approach to the hip has been performed after removal of part of the Gluteus maximus muscle. Which of the following choices correctly identifies structures A, B, and C in Figure A?
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A: Gluteus minimus, B: Piriformis tendon, C: Sacrotuberous ligament
n Figure A, the arrow labeled A is pointing to the Gluteus minimus muscle, B is pointing to the tendon of the piriformis muscle, and C is pointing to the sacrotuberous ligament (Illustration A). These are all important landmarks and points of identification during a posterior approach to the hip. Illustrations B and C demonstrate the relationship of the ischial spine and ischial tuberosity in relation to the hip joint and the associated ligaments. The superior gemellus originates from the ischial spine. |
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Which of the following structures does NOT exit the pelvis proximal to the anatomic landmark identified in Figure A
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Obturator internus
The arrow points to the ischial spine and is the site of attachment of the sacrospinous ligament which anatomically divides the greater and lesser sciatic notches. The contents of the greater sciatic notch include the piriformis, the superior and inferior gluteal vessels and nerves, the sciatic and posterior femoral cutaneous nerves, the internal pudendal vessels, and the nerves to the obturator internus and quadratus femoris. The lesser sciatic notch is home to the tendon of the obturator internus, the nerve which supplies that muscle, and the internal pudendal vessels and nerve that course back through the lesser notch after having exited the greater notch. |
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All of the following structures pass below the piriformis through the greater sciatic foramen EXCEPT:
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The pudendal nerve, sciatic nerve, inferior gluteal nerve, and inferior gluteal artery all exit the sciatic foramen. The obturator nerve does not exit the sciatic foramen. The greater sciatic foramen is bounded as follows: anterolaterally by the greater sciatic notch of the illium, posteromedially by the sacrotuberous ligament, inferiorly by the sacrospinous ligament and ischial spine, and superiorly by the anterior sacroiliac ligament. It is partially filled up by the piriformis which leaves the pelvis through it. The following structures make their exit from the pelvis through the greater sciatic foramen above the piriformis: superior gluteal vessels and superior gluteal nerve. Below the piriformis the following structures exit: inferior gluteal vessels, inferior gluteal nerve, internal pudendal vessels, pudendal nerve, sciatic nerve, posterior femoral cutaneous nerve, nerve to obturator internus, and nerve to quadratus femoris. The obturator nerve originates from the L2, L3, and L4 nerve roots, exits the pelvis through the obturator foramen, innervates the gracilis, adductors (longus, brevis, magnus), and provides sensation to the inferomedial thigh
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Origin Dorsal ilium inferior to iliac crest
Insertion Lateral and superior surfaces of greater trochanter Action Major abductor of thigh; anterior fibers help to rotate hip medially; posterior fibers help to rotate hip laterally Innervation Superior gluteal nerve (L4, L5, S1) (L4, L5, S1) Arterial Supply Superior gluteal artery |
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In a modified Hardinge (lateral) approach to the hip, what structure limits the proximal extent of the gluteus medius split
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Superior gluteal nerve
The superior gluteal nerve enters the deep surface of the gluteus medius approximately 5 cm proximal to the tip of the greater trochanter. Splitting the muscle, as in the Hardinge approach, has been reported to cause injury to this nerve if the split is carried above 5 cm. |
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Which of the following approaches for total hip arthroplasty is reported to have the lowest prosthetic dislocation rate? Topic
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The direct lateral (Hardinge) approach has been cited to have the lowest associated dislocation rate of the options provided However, the article also found that the incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to 16% for patients who had the posterior approach.
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Which of the following describes the internervous plane of the direct lateral approach to the hip?
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No true internervous plane as the dissection splits a muscle innervated by the superior gluteal nerve
The direct lateral approach (Hardinge) splits the fibers of the gluteus medius which is innervated by the superior gluteal nerve. The anterior approach employs the interval between the sartorius/rectus femoris (femoral nerve) and TFL/gluteus medius (superior gluteal nerve). The posterior approach utilizes the interval between the gluteus maximus (inferior gluteal nerve) and the gluteus medius (superior gluteal nerve). |
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Origin Anterior surface of lateral process of sacrum and gluteal surface of ilium at the margin of the greater sciatic notch
Insertion Superior border of greater trochanter Action Lateral rotator of the hip joint; also helps abduct the hip if it is flexed Innervation Piriformis nerve (L5, S1, S2) (L5, S1, S2) Arterial Supply Superior and inferior gluteal and internal pudendal arteries |
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Which of the following muscles originates from the ventral surface of the sacrum?
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Piriformis
: Of the muscles listed, only the piriformis muscle originates from the ventral surface of the sacrum.Illustrations A and B show the origin and insertion of the piriformis muscle from the sacrum to the piriformis fossa on the proximal femur. Illustration C is a T1 MRI showing the origin of the piriformis muscle from the ventral surface of the sacrum. (a) shows the right piriformis muscle overlying the S2 nerve (arrow). (p) shows the left piriformis muscle. |
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The inferior and superior gluteal nerves are designated as such based on their relationship to what structure?
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The piriformis muscle
: The superior gluteal nerve arises from the posterior roots of L4, L5 and S1 in the lumbosacral plexus. It exits the pelvis through the superior part of the greater sciatic notch, just superior to the piriformis tendon. It courses between the gluteus medius and minimus, supplying both muscles, as well as the tensor fascia lata. The inferior gluteal nerve arises from the posterior roots of L5, S1 and S2 in the lumbosacral plexus and exits the pelvis through the greater sciatic notch, under the piriformis. It courses on the deep surface of gluteus maximus and provides the sole motor innervation for this muscle. |
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A 24-year-old female marathon runner experiences gradual onset of right groin pain. Initially it was only painful during running, but now it is painful with walking. She has no mechanical symptoms and denies back or lower leg symptoms. On exam, she has pain when attempting a straight leg raise and with passive internal rotation of the hip. Pelvis and hip radiographs demonstrate normal acetabular version and normal femoral head-neck offset. What is the next most appropriate step in her care?
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MR imaging of the hip
Gradual onset, progressive groin pain in a marathon runner is concerning for a femoral neck stress fracture, which warrants further imaging such as an MRI or bone scan. Normal radiographs are common and do not preclude the presence of a stress fracture. Treatment recommendations are based on the location and severity of the fracture. Compression-sided fractures are usually treated non-operatively, with protected weight-bearing until pain-free, and cessation of running until healed. Tension-sided fractures and fractures that involve more than 50% of the femoral neck are generally treated operatively with percutaneous screw placement. A careful evaluation of the training regimen, dietary history, and menstrual history should also be performed. |
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A 20-year-old male marathoner has had left sided groin pain for the past 4 weeks. He has continued to maintain his routine running regimen despite the discomfort. Radiograph, bone scan, and MR images are shown in Figures A-D. What is the most appropriate next step in management?
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he patient's history and imaging are consistent with a femoral neck stress fracture. While most compression-sided fractures may be treated non-operatively with protected weightbearing, percutaneous screw fixation is indicated for tension-sided fractures and compression-sided fractures that extend greater than 50% of the way across the neck, as in this case.
The fracture is not evident on the pelvis radiograph but is visualized on the bone scan, T1, and T2 MR images. Bone density is not an important consideration in the decision to surgically treat a stress fracture of the hip, however whether the stress fracture is compression versus tension-sided is important. A visible fracture line on radiographs obviates the need for a MRI and increases the likelihood of displacement being present. Displaced femoral-neck fatigue fractures are urgent surgical situations. |
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) A 23-year-old professional pitcher complains of posterior shoulder pain. Physical exam is notable for scapular dyskinesis. No intra-articular pathology is found on shoulder MRI. Which of the following should be emphasized in the initial stages of rehabilitation?
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Coordination of scapular motion with trunk and hip movements
Scapular dyskinesis is an alteration in the normal motion of the scapula during coordinated scapulohumeral movements. It occurs as a sequela of prior shoulder injury, especially injuries disrupting the activation patterns of scapular stabilizing muscles. Kibler et. al outlined a rehabilitation protocol to treat scapular dyskinesis. The principle is to treat the problem from proximal to distal. The first stage involves attaining full motion of the scapula and coordinating the scapula with trunk and hip motions. Once this has been achieved, the second stage involves strengthening the scapular musculature. As scapular control is attained, exercises are introduced that place emphasis on the shoulder and arm beginning with flexibility and closed-chain strengthening, and eventually working up to sport-specific functions. Progress is determined by functional improvement rather than a strict time table. core strengthening scapular stabilizers, serratus anterior, trapezius rotator cuff muscles teaching proper core mechanics in throwers |
