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Terms in this set (172)
What is the average size of supraspinatus tendon?
What size of tear designates a partial thickness tear of supraspinatus?
6-7 mm = 50% partial thickness tear
What is blood supply of rotator cuff?
Subscapular, suprascapular, and humeral circumflex arteries
Which side of rotator cuff is more vascular, bursal or articular?
Bursal! Articular = weaker, more tears.
MCC of shoulder pain?
Subacromial impingement. First stage of rotator cuff disease.
After how many months of nonoperative treatment should you suggest surgery for subacromial decompression (impingement sx's)?
Minimum 4-6 months.
What kind of rotator cuff repair can indicate a subacromial decompression and RC debridement, instead of full repair?
low-grade partial ARTICULAR sided rotator cuff tear
How long is postop healing take for RC repair?
Pec major tendon transfer for RC is indicated for what kind of tear?
Latissimus dorsi tendon transfer is indicated for what kind of RC tear?
Large supraspinatus and infraspinatus tears
Which physical exam tests indicate supraspinatus damage?
Drop arm and Empty Can test
Which physical exam tests indicate infraspinatus damage?
ER Lag sign
Which physical exam tests indicate Teres Minor damage?
Hornblowers (Pain with external rotation with arm 90 abducted and 90 degrees ER)
Which physical exam tests indicate subscapularis damage?
Belly press (press hand against belly button, ++ if they have to flex wrist to accomdate) and lift off (Hand is on low back with palm facing out, press away from back, ++ if pain or weakness)
What are the 4 operative treatment options for RC repair?
Subacromial decompression & RC debridement alone, Arthroscopic repair, Tendon transfer, reverse total shoulder arthroplasty
What are nonsurgical risk factors for a RC failure to repair after surgery?
Smoking, age < 65 y/o, diabetes, large tear size >5cm,
What does TUBS stand for?
Traumatic Unilateral dislocation with a Bankart lesion requiring Surgery
If rotator cuff is irreplaceable, which type of shoulder replacement would you prefer?
Reverse total shoulder, or hemiarthroplasty
(Not total shoulder arthroplasty)
Indications for shoulder replacement?
Night pain, reduction of daily activities.
Posterior humeral head subluxation
Glenoid chondral wear to bone (no more cartilage)
1st line treatment for POSTERIOR shoulder dislocation?
Reduction and immobilization in external rotation for 4-6 weeks. 10-20 degrees external rotation, elbow at side.
After 6 weeks, PT.
What is a GIRD injury? Most common mechanism/group of patients?
Glenohumeral Internal Rotation Deficit
MC in overhead sports, especially pitchers
Common physical exam finding for patient with GIRD?
Reduced internal rotation, increased external rotation.
May be painless, but have complaints of reduced ball throwing ability
Nerve innervation of biceps brachii, brachioradialis and coracobrachilalis?
Musculocutaneous nerve (C5 - C7)
What does the thoracoacromial artery branch off of?
What are the branches (4) of the thoracoacromial artery?
The Upper trunk of brachial plexus refers to which nerve roots?
Function of serratus anterior muscle?
Elevate arm horizontally.
The long thoracic nerve leaves the brachial plexus where?
Directly off superior roots (C5-C6), and descends inferiorly.
Which muscle of the hand allows for ADDuction of the fingers?
They also flex the MCP's
Which muscle of the hand allows for ABduction of the fingers?
Also assist in flextion of MCP's, and extension of PIP's and DIPs of index, middle, and ring finger.
What does the intercostabrachial nerve do, and what specific intercostal nerve does it arise from?
Arises from 2nd intercostal, and supplies sensory to cutaneous section of medial side of arm.
Weakness in pronation of arm invovles what nerve?
Median nerve innervates:
What nerve allows ability to oppose and flex thumb?
Which muscle flexes the DIP joints?
Flexor digitorum profundus
Which muscle flexes the PIP joints?
Flexor digitorum superficialis
Function of lumbricals?
flex at the MCP
extend at the PIP/DIP
Which muscle ADDucts the arm?
Contents of antecubital fossa from medial to lateral? (4)
Biceps brachii tendon
During repair, what nerve is at most risk for damage during distal biceps tendon rupture repair?
Latearl antebrachial cutaenous nerve runs just medial to tendon of distal bicep.
Studies show that greater than __ pitches per game and/or __ months of competitive pitching puts you at high risk for little leaguers elbow (medial apophysitis).
80 pitches per game and 8 months per year.
what are the 5 tests for Beighton's hypermobility screening?
Extend fifth MCP > 90 degrees
Extension in knees > 10 degrees
Extension of elbow > 10 degrees
Forward flexion of trunk, with palms reaching floor
Apposition of thumb to forearm
What muscles does the axillary nerve supply motor function to?
Triceps (long head)
After how many days can a healed tendon tolerate controlled active motion?
How many pulleys are in each finger?
9: 5 annular and 4 crucifrom
In thumb, 2 annular, 1 oblique pulley
Which pulley on fingers 2-5 are most important to fix? Why?
A2 pulley (and A4), to prevent bowstringing
What can be grafted to repair pulley?
Palmaris or plantaris
Claw hand is known as what?
Curling of fingers, usually due to ulnar nerve palsy (4th and 5th fingers). Commonly seen with hypothenar atrophy.
The palmar interossei (which adduct fingers), are attached to which digits?
2nd, 4th and 5th digits.
Scaphoid fracture often injures which artery?
What nerve can often be injured in supracondylar fractures?
Median nerve passes near supracondylar area.
What structures lie superficial to the flexor retinaculum?
Ulnar artery, ulnar nerve, palmaris longus tendon, and palmar cutaenous branch of median nerve.
Patients with a Bennet fracture most likely injure what muscle/tendon?
Opponens pollicus inserts on first metacarpal
All other intrinsic thumb muscles (abductor pollicus brevis, flexor pollicus brevis, adductor pollicus brevis) insert on proximal phlanages.
What is a Bennet fracture? (bonus! Name of more acute version?)
Fracture at base of first metacarpal.
Comminuted bennet fracture is known as a Rolando fracture.
What two tendons pass through the "common flexor sheath of hand"?
Flexor digitorum profundus and superficialis
FYI: Flexor pollicus longus has it's own sheath
Supraspinatus is innervated by what?
This also innervates the infraspinatus!
What innervates the palmar and dorsal interrosei?
What is a jersey finger?
Injury to flexor digitorum profundus in zone 1, not allowing flexion of DIP.
There are 4 types. TYPE 1 = emergent surgery, tendon retracted to palm, which leads to vascular disruption.
LOOK for avulsion fracture on distal phalanx.
Describe the different zones of flexor injuries of the hand. (I - V)
Zone I: Distal to FDS insertion.
Zone II: FDS insertion to distal palmar crease
Zone III: Palm (distal palmar crease, to distal intersection of thumb to palm)
Zone IV: Carpal tunnel
Zone V: Wrist to forearm
Injury in zone II of hand often involves what special circumstance?
Usually involves damage to both FDS and FDP, since they are in the same tendon sheath in that area.
What digit has a higher re-rupture rate, thumb or fingers?
(Due to # pulley's?)
A fracture where on the scaphoid leads to 100% chance of AVASCULAR NECROSIS?
Proximal 5th of bone
Proximal 1/3 of bone = 33% chance.
Scaphoid fracture = thumb spica splint and follow up in how many days?
12-21 days. After viewing xrays and physical exam.
Length of casting depends on location of NON-DISPLACED fracture for scaphoid injuries, what are the time lengths?
Distal-waist fracture = 3 months
Mid-waist = 4 months
Proximal 1/3 = 5 months
Three physical exam findings for scaphoid fracture?
Pain with resisted pronation
Scaphoid tubercle tenderness volarly
Describe an amputation injury to fingers that does NOT require surgery?
Adult and children with NO exposed bone or tendon, and < 2 cm of skin loss.
Allow healing by secondary intention.
How long will healing take from amputation if it is dealt with non-operatively?
After 7-10 days in cast, start daily soaks in water/peroxide, followed by soft dressing and fingertip protector.
Skier's thumb is damage to which ligament?
Ulnar collateral ligament
Damage to UCL in thumb from Skier's thumb may result in what special tissue damage?
Distal end of proximal phalanx of thumb is avulsed from UCL tear, and a flap covers the bone, hiding lesion.
Radial head articulates with what part of humerus?
Proximal ulna articulates with what part of the humerus? (3)
Trochlea, coronoid fossa, and olecranon fossa
What is an Essex-Lopresti lesion?
Radial head fracture-dislocation with associated interossesous ligament and distal radioulnar joint disruption
If radial head is a displaced fracture, what criteria would need to be present to NOT operate?
Isolated nondisplaced (no capitellar damage, radioulnar joint disruption), and no block to elbow motion.
How quickly should patient perform ROM exercises after nondisplaced radial head fx?
24-48 hours after injury.
They should be in a sling for first two days, however.
Indications for operative treatment of radial head Fx?
Displacement >2mm (>25% of radial head circumference) or any angulation of bone, possible mechanical block to forearm rotation.
Comminuted and displaced Fx, mechanical block to rotation.
ORIF repair of radial head fractures with __ or more fragments have poorer outcome?
3 or more fragments have a poorer outcome than < 3.
Thumb pain from skier's thumb should include which XRay in particular?
Comminuted fractures should get what other imaging?
When is a radial head arthroplasty indicated?
Comminuted fracture with 3 or more fracture pieces, and where ORIF is not feasible, and >25% of radial head.
How long should immobilization last after radial head ORIF?
MAXIMUM 5-7 days. Early flexion, extension, supination and pronation should be initiated.
What films should be ordered for suspected radial head fx?
Lateral, AP, oblique (greenspan).
What is a Barton fracture?
intra-articular distal radius fracture with carpal displacement. volar involvment is more common
Where is Lister's tubercle and what passes by it (and where specifically?)
Lister's tubercle is on dorsal surface of distal radius. The Extensor pollicus longus passes laterally to the tubercle.
Normal radiographic relationships for distal radius?
Radial inclination averages 23 degrees (13-30)
Radial height averages 11mm (8-18 mm)
Volar tilt averages 11-12 degrees, (0-28)
Acceptable articular stepoff in a distal radius fracture?
Acceptable amount of radial shortening in distal radius fracture?
< 5 mm
Acceptable amount of volar tilt in distal radius fracture?
< 5 degrees dorsal angulation or within 20 degrees of contralateral distal radius.
How do you measure carpal alignment?
One parallel line through the center of the radius, another parallel and through the capitate bone. They should intersect within the carpal bones.
Tx for lunate dislocation?
Emergent closed reduction,followed by ORIF for all acute injuries < 8 weeks old.
Tx for chronic lunate dislocation? (injury > 8 weeks old)
proximal row carpectomy
What is Keinbock's disease?
AVN of the lunate, leading to abnormal carpal motion.
Definitive treatment for Keinbock's disease?
Proximal row carpectomy
What are early signs of Keinbock's disease on XRay?
Stage I = No visible changes, MRI needed.
Stage 2 = Sclerosis of lunate
Stage 3 = Lunate collapse, no scaphoid rotation
Stage 4 = Lunate collapse, fixed scaphoid rotation
Lateral epicondylitis is most likely caused by what muscle?
Extensor Carpi Radialis Brevis
Microtrauma to the avascular tendon causes it to try to repair the area with collagen, causing tendinosis.
What's a good physical exam test for lateral epicondylitis?
Have patient pronate forarm and have wrist in flexion causing pain to lift chair.
Having forearm in supination and grabbing chair will cause less pain or none at all.
What should be on your differential for lateral epicondylitis?
Supinator syndrome (radial tunnel syndrome).
Tumor loose bodies
Muscles (2) most likely involved with medial epicondylitis?
Pronator teres or flexor carpi radialis
What should you also check for when assessing medial epicondylitis?
Surgical treatment for lateral and medial epicondylitis? What other condition associated with medial would cause worse outcomes?
Debridement of scar tissue around tendon origin, vascularization.
Ulnar neuritis with medical epicon will yield poorer outcomes.
Post-op splint/sling for medial and lateral epicondylitis surgeries?
Sling for 2-3 days, removable wrist splint for 1-2 weeks to prevent wrist extension/flexion.
What will the patient lose if they decide to not operate on a partial or full thickness biceps tendon rupture?
Can lose 50% of supination power and 30% of flexion power.
What two nerves can be damaged during distal biceps tendon repair?
Lateral antebrachial cutaenous and posterior interosseous
When should patient begin full ROM after distal biceps tendon repair?
2 days! NO RESISTANCE. Active motion.
Should have full ROM in 2-3 weeks.
How long is the arm immobilized after a triceps rupture tendon repair? How long until they can weight bear?
3-4 weeks in a cast, at 30-45 degrees of flexion.
No weight bearing for 4-6 months!
Nonop treatment for olecranon fracture?
If fracture is nondisplaced, immobilization in a long arm cast in 45-90 degrees of flexion. In reliable patients, ROM in 5-7 days can be initiated.
Fracture not complete until 6-8 weeks, follow up radiographs a must.
Two most common complaints of surgical olecranon fracture repair?
Symptomatic hardware (80%) - 45% will want removal
Half of cases note decreased ROM in elbow, but most patients not little if any limitation.
With ulna/radial shaft fractures, what x-rays should be ordered?
AP and lateral views of the forearm, and possibly oblique
ALSO - ipsilateral wrist and elbow to rule out dislocation of DRUJ. RADIAL HEAD MUST be aligned with capitellum in all views.
What features of ulna shaft fracture would require ORIF?
> 10 degree angulation in any plane, or >50% displacement of the shaft.
Nonop treatment for ulna nighstick fracture?
Immobilization for 7-10 days, then functional bracing for 8 weeks.
What are 4 radiographic signs of injury to the DRUJ?
Fracture at base of ulnar styloid
Widened DRUJ on AP
Subluxed ulna on lateral x-ray
>5-mm radial shortening.
Nondisplaced radial shaft fractures are treated with a long-arm cast. Evidence of what (besides nonunion or displacement) would indicate ORIF?
Loss of radial bowing
Postop management for a Galeazzi fracture?
If DRUJ is stable, early motion.
If DRUJ is unstable, immobilize forearm in supination for 4-6 weeks in long arm cast.
When is Nonop appropriate for distal radius fractures?
Nondisplaced or minimally displaced.
Displaced with a stable fracture pattern and acceptable radiographic parameters
Low demand, elderly patients.
What would make a scaphoid fracture UNstable?
>1 mm displacement
> 10 degrees angular displacement
Occult scaphoid fracture treatment?
Can't see it on xray, but PE findings suggest Fx?
Immoblize 2 weeks in thumb spica. Repeat xrays on follow up.
If pain is present but xrays normal, consider MRI or continue casting.
What is the last bone to ossify in the hand?
Pisiform, at age 12.
Fractured hook of hamate may cause damage to what vessels?
Ulnar nerve and artery (part of Guyon's cannal)
What would be an indication of carpal instability on xray?
Disruption of Gilula's lines
Overlapping of carpal bones (articulating bones should have 2mm or less apart)
How much displacement in a scaphoid fracture indicates ORIF/screw placement?
> 1mm !
Name four indications for ORIF for scaphoid fracture besides nonunion
Displacement > 1 mm
Proximal pole fracture
Assoc with perilunate dislocation
Vertical or oblique fracture
What causes SLAC wrist?
Chronic dislocation between lunate and scaphoid.
It stands for Scaphoid Lunate Advanced Collapse
(Extension of Lunate, Flexion of scaphoid)
Stage II+ = proximal row carpectomy
Union rate of scaphoid fracture after ORIF?
90-95% (if operated within first 4 weeks)
Tx for metacarpal head fracture?
ORIF, ORIF, ORIF
When should you operate on metacarpal SHAFT fractures?
Index & Long finger angulation > 20 degrees
Ring Finger angulation > 30 degrees
Little finger angulation > 40 degrees
Treatment for nonoperative metacarpal shaft fractures?
Cast for 4 weeks, flex MCP joints 70-90 degrees
(Ulnar gutter for 4th or 5th MC Fx)
The collateral ligaments of the MCP joint are relaxed in what position?
Relaxed in extension, permitting lateral motion.
Why should you keep MCP joints flexed after metacarpal ORIF or fractures?
Considered the "protected position", Keeps collateral ligaments tight, and minimizes joint stiffness
Common associated injury with metacarpal head fractures?
Collateral ligament damage
What three things decide treatment of metacarpal neck fractures?
Which finger it is
Appropriate splint and placement of hand for metacarpal neck fractures? (4th and 5th digit)
Ulnar gutter splint, with wrist in 30 degrees extension, and MCP's in 70 degrees of flexion.
What physical exam evidence of metacarpal neck fracture would indicate surgery?
Pseudoclawing of fingers (neck flexion due to Fx, causing MCP extension, and PIP flexion)
Innervation of the triceps?
Acceptable metacarpal shaft shortening after fracture for all digits?
Acceptable metacarpal NECK fracture angulation?
Index and long finger = 10-15 degrees
Ring finger = 40 degrees
Little finger = 60 degrees
What type of metacarpal fracture should you really look out for rotation?
Oblique fractures of the metacarpal
Acceptable alignment for humeral shaft fractures for Nonop?
< 20 degrees anterior angulation
< 30 degrees varus/valgus angulation
< 3 cm of shortening
Indications for operative humeral shaft fracture?
Forearm fracture (floating elbow)
Brachial plexus injury
Vascular injury requiring repair
Is radial nerve palsy an indication for surgery after humeral shaft fracture?
Union rate is at risk with humeral shaft fractures with what type of bone break?
Proximal third oblique or spiral fractures
What is the union rate of humeral shaft fractures that do not have operative intervention (given appropriate radiographic alignment)?
Treatment for greater tubercle fracture on proximal humerus? How displaced does the greater tubercle need to be?
ORIF!, > 5mm (most likely best visualized on CT)
Mid-clavicle fracture requirements for operation?
100% displaced and > 2 cm of shortening
For distal clavicle fractures, it is more stable and often nonoperative if fracture is where?
Lateral to coracoclavicular ligaments. (assuming they are not torn and there's no significant medial clavicle displacement)
Nonunion rate of distal clavicle fractures that are medial to coracoclavicular ligaments?
Up to 56% will not heal if fracture is medial to CC ligaments.
What are the coracoclavicular ligaments called?
Conoid ligament and trapezoid ligament
Nerve sensation to medial part of calf and foot?
Nerve sensation to lateral/posterior calf and lateral ankle?
Nerve sensation to middle lower leg and top of foot?
Superficial peroneal nerve
Innervation to anterior compartment of leg?
Deep peroneal nerve
Contents of anterior compartment of leg?
Tibialis anterior (dorsiflexes ankle, inverts foot), Extensory Digitorum Longus, Extensor hallicus longus, Fibularis tertius (dorsiflexes ankle, helps with ankle eversion).
What muscles make up the lateral compartment of the leg?
Fibularis longus, Fibularis brevis
Both work to evert ankle.
Muscle innervation to lateral compartment of leg?
Superficial fibular nerve
What two nerves are nearby during a Brostom procedure?
Superficial peroneal nerve (medial)
Sural nerve (posterior/lateral)
What is a Lisfranc fracture?
Fracture-Dislocation of the metatarsals and tarsals. Commonly the 2nd metatarsal and medial cuneiform
What tarsal bone do the 4th and 5th metatarsals articulate with?
What does the navicular bone articulate with?
The medial, middle and lateral cuneiform bones anteriorly, cuboid laterally, and talus posteriorly.
Proximal and Middle phalanx fractures can be treated nonoperatively when?
When they are extraarticular
WITH < 10 degrees angulation or < 2mm shortening and no rotational deformity
OR nondisplaced intraarticular fractures
How long and what type of treatment for nonoperative proximal and middle phalanx fractures?
3 weeks of immobilization (buddy tape vs splinting) followed by aggressive motion rehab.
What percentage of mucous cysts from arthritis spontaneously resolve?
What is the major muscle group for supination?
Biceps tendonitis physical exam test?
Forward flex shoulder, keep elbow in full extension, hand in full supination. Pain with resistance to forward flexion
Surgical treatment for SNAC wrist?
4 corner arthrodesis with scaphoid excision.
When do you operate on Ulnar collateral ligaments of thumb?
Complete avulsion of ligament (usually > 20 degrees side to side variation in valgus/varus)
Or (+) Stenor Lesion
Differential for ulnar sided wrist pain?
Ulnar impaction syndrome
DRUJ joint arthritis
Lunar-triquetral Ligament tear
What's a good trick for checking malrotation in a radius bone fracture?
Bicipital tuberosity and radial styloid should be 180 degrees from each other on AP.
Surgical treatment for ulnar impaction syndrome?
Ulnar shortening osteotomy
Bilateral ulna and radius fractures in a child < 10 years old can tolerate how much angulation? Child > 10 years old?
Following closed reduction, < 15 degrees angulation, < 45 degrees rotation
10+ years old (still skeletal mature), following closed reduction, < 10 degrees angulation, < 30 degrees.
What percentage of supination strength comes from biceps? Percentage of arm flexion?
60% of supination
40% of arm flexion
How do you classify coronoid process fractures?
Type 1 - Coronoid tip process fracture
Type 2 - 50% of coronoid process
Type 3 - >50% of coronoid process
When is nonoperative appropriate for a coronoid process fracture?
Minimally displaced type 1, 2 or 3 fractures with STABLE ELBOW
When do you operate on coronoid process fractures?
Type 1, 2 or 3 fractures with persistent elbow instability, olecranon fracture, or loose bodies.
Operative intervention indications for distal phalanx?
there is nailbed injury
dorsal base fractures with >25% articular involvement
displaced or irreducible
How much dorsal angulation can a child < 9 years old tolerate on a distal radius Fx? > 9 years?
< 9 years = 30 degrees
> 9 years = 20 degrees
Will still need closed reduction if > 10 degrees!
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