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joint injury

joint injury. Affection shoulder Affection knee Affection elbow 4. Affection hip. Affections of shoulder. Anatomy 1. joint of shoulder 1> acromio-clavicular joint : disc 1) acromio-clavicular lig: disc

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joint injury

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  1. joint injury Affection shoulder Affection knee Affection elbow 4. Affection hip

  2. Affections of shoulder • Anatomy 1. joint of shoulder 1> acromio-clavicular joint : disc 1) acromio-clavicular lig: disc 2) coraco-clavicular lig: coronoid & trapezoid lig. 2> sterno-clavicular joint 3> scapulo-thoracic joint 4> gleno_humeral joint: compare with head glenoid cavity is small and thin cause wide ROM but unstable.

  3. 2. Ligaments from coronoid process 1> coracohumeral lig. 2> coracoacromial lig. 3> coracoclavicular lig. 3. Movement of the shoulder joint 1> flexion: 1) ant. Fiber of deltoid 2) coracobrachialis 2> extension: 1) latssimus dorsi 2) teres major 3> abduction: 1) deltoid 2) supraspinatus

  4. 4> horizontal abduction: 1) post. Fiber of deltoid 5> horizontal adduction: 1) pectoralis major 6> external rotation: 1) infraspinatus 2) teres minor 7> internal rotation: 1) subscapularis

  5. II. Biomechanics glenohumeral motion scapulothorcic motion eg) abduction 180°= gelnohumeral motion 90 - 110° + scaulothoracic motion 70-90 ° *clavicle motion: 40-60 °

  6. III. Thoracic outlet syndrome 1> cervical rib syndrome 2> scalenus anticus syndrome 3> costoclavicular syndrome 4> hyperabduction syndrome

  7. 1. Cervical rib syndrome -characteristics: from 7th cervical spine -anatomy: 1>bone or fibrous band 2>brachial plexus &subclavian a. -> overcervical rib going through the cervical rib &scalenus space. 3>c8 & T1 compression -Symptom: 1> pain or radiating pain to medial side of shoulder, forearm 2> paresthesia in ulnar N. area 3> radial A. pulse weakness

  8. Adson’s test: is the loss of the radial pulse in the arm by rotating the head to the ipsilateral side following deep inspiration Diagnosis 1> simple X-ray 2> arteriograph: valuable Tx: 1> conservative: Posture correction and shoulder girdle strengthening exercises for the muscles, working posture, changes in sleeping habits. 2> operative: 1)cervical rib rimoval 2)scalenus anticus resection 3) Ist rib resection

  9. 2.Scalenus anticus syndrome -anatomy: abnormal hypertrophied scalenus -characteristic: 1)Prevalent in middle age 2)later than cervical rib syndrome 3) Prevalent in women (female) Sx & sign: similar with cervical rib syndrome Diagnosis: 1>angiography 2>MRI: scalenus anticus – hypertrophy Tx: 1>conservative : 2>operative

  10. 3.Costoclavicular syndrome -anatomy; clavicle &1st rib space –narrowing or deformity d/t 1)cerviothoracic scoliosis 2)clavicle fracture 3)nonunion or excessive callus of 1st rib 4)occupational problem 5)atrophy of m. of shoulder girdle -Wright test(=costoclavicular maneuver) :

  11. 4.Hyperabduction syndrome -anatomy: over abduction upper arm->teres minor tension->neurovascular structure tractioned by over hanging coracoid process d/t 1) repetitive trauma of neurovascular structure -Hyperabduction test *also positive at normal population Tx: 1) conservative: posture correction 2) operative: release or resectomy

  12. IV. Subacromial Syndrome • Subacromial space: • Subacromial bursa: • Subteltoid bursa:

  13. 1.Supraspinatus tendinitis rotator cuff : 1,2,3,4, d/t rotator cuff ->degenerative change Mechanism: 1. upper arm abduction 2.supraspinatus glipped at humerus greater tubucle &acromion 3.With aging protection of the bursa weak, and continued trauma mechanical stimuli and inadequate recovery 4.supraspinatus –early phage wear,local ischemia, inflammation stage, calcification

  14. Acute inflammation stage(=chemical furuncle) -acute calcareous tendinitis; calcifications - 25-45 yrs - rotation, abduction ->limitation sagital plane motion -> not limited Chronic tendinitis(=painful arc syndrome) -50-60yrs -shoulder jt, 60-90°abduction-> contact with acromion lesion site-> pain D/Dx: degenerative artiritis of acromioclavicular joint (90°이상의 전범위)

  15. 2.Bursitis Subacromial bursitis -supraspinatus lesion->scar tissue->bursal hypertrophy -Snapping shoulder : coracoacromial lig. -Dawbarn’s sign; pain at greater tubercl of humerus , when over abduction ,bursa placed at under acromion, pain release. subcoracoid bursitis subscapular bursitis

  16. 3.Impingement Syndrome -Subacromial space : humeral head ->acromion -Rotator cuff 1)supraspinatus 2)infraspinatus 3)teres minor 4)subscapularis -shoulder pain was main reason d/t degenerative change of rotator cuff

  17. Stage of impingement syndrome

  18. Mechanism : • Upper limb abduction • Supraspinatus clipping between humerus great tubercle & acromion • With increasing age the protection of the bursa was weak, ongoing trauma due to mechanical stimulation and inadequate recovery • Supraspinatus early wear, local ischemia, inflammation, calcification *Dawbarn’s sign: pain at humerus great tubercle painless when complete abduction-> bursa placed at sub acromion.

  19. Sx & sign • Night pain (Characteristic) • Pain at: 90° abduction; sudden arm flexion • Impingement sign: 90°flexion &internal rotation upper arm • Always combined Secondary biceps longhead rupture with supraspinatus rupture Dx: 1.shoulder series X –ray: 1) sclerosis around acromion 2) sclerosis &cystic change around greater tubercle 2.athrogram 3. MRI

  20. Tx. • Conservativ Tx. • Operative Tx. : after conservative Tx 3Ms, still have symptom. 1) ant. acromioplasty

  21. 4.Rupture of supraspinatus tendon • Trauma history • Degenary change : essential prerequisite rupture • Partial tear : self healing possible Complete tear (x) - 45-65 yrs

  22. Sx & sign: -supraspinatus single rupture: abduction possible -rotator cuff widely rupture: abduction impossible *shrugging: abduction impossible, attempt to abduction *abduction paradox: *drop arm sign: Tx. • 90% non surgery healing • Partial rupture: conservative Tx • Complete rupture: conservative Tx at once->operative Tx • Old rupture: not need surgery

  23. 5.Tenosynovitis of Biceps 40yrs Female digging or throwing ball Sx & sign -direct pain in groove of biceps long head tendon -Speed test: elbow jt. Extension & forearm supination, flexion shoulder jt. Under Constant resistance ->pain -Yergason’s test: elbow jt. Flexion, supination forearm under Constant resistance ->pain Tx.: - conservative Tx. - operativer Tx.

  24. Adhesive Capsulitis, Frozen Shoulder 1. intrinsic factor 1)calcareous supraspinatus tendinitis 2)partial tear of rotator cuff 3)biceps tendinitis 4)prolonged immobilization 2. extrinsic factor 1)myocardial infarction 2)HIVD in cervical spine 3)CVA 4)reflex sympathetic dystrophy -45-60yrs.

  25. Sx & sign 1)pain: aggrevated by abduction, E/R, extension 2)stiffness 3)tenderness: Inferior shoulder Tx. - several months Physical Therapy - important to convince the patients it may fully recovered - conservative Tx. 1)thermal therapy 2)exercise : pendulum exercise -> finger tip wall climbing exercise (A/A movement) 3) NSAID, steroid 4) Manipulation

  26. Humeral Lateral Epicondylitis (tennis elbow) Charac: 1) humeral lat. Epicondyle origin common extensor tendon fiber contusion 2) tennis, golf hitting the ball moment , elbow have the varus force; When the extensor muscle tensioning in semipronation and racket is designed for faster than expected rush to elbow flexion and forearm extensor muscle at the moment is to hyperextension occurred Sx: 1) Turn the knob / twist a towel 2) Kettle holding the handle 3) Forearm caracole top of the hard lifting heavy objects Tx: 1.conservative Method 1)NSAID 2)Procaine +25mg Hydrocortisone : local inj 1-2 time 2. operative method

  27. Trigger Fignger & Thumb Charac: 1) thumb or finger, flexion or extension limitation at an angle +snapping sound 2) d/t trauma of rheumatoid synovitis Patho: 1) localized stenosis of flexor tendon sheath, located near the MP jt 2)2nd: nodular thickening of the tendon ->disturbing smooth sliding in tendon sheath Tx: 1) cast splint & hydrocortisone 2)MP jt area skin transverse dissection ->A 1 pulley(1st annular pulley) longitudinal incision -> stenosis site open & removal

  28. Avascular necrosis of the hip 1.Symptomatic a.Traumatic (Neck fracture,dislocation) b.Embolism (decompression sickness, Siconkle cell anemia, Gaucher’s disease) c.postirradiation 2.Idiopathic – fat embolism, vascular lesion, coagulation defect 3.Male : female = 3:1 4.Sclerosis and lucency, Subchondral fracture (Cresent sign) 5.Core decompress, living bone graft, rotational osteotomy, arthroplasty

  29. Affections of Knee Anatomy 1. lateral qudaruple complex of Nicholas : lateral collateral lig., illiotibial band, biceps femoris tendon, popliteus tendon 2. Medial quadruple complex : medial collateral lig., semimembranosus, pes anserine muscle, oblique popliteal lig. 3. Semilunar cartilage (meniscus) : transmit about half the axial loads across the joint lateral meniscus more wide , O type ; medial meniscus more big 4.ligaments strength : tibial collateral =ACL= 1/2PCL function: ACL: prevent tibia anterior translation & hyperextension; control rotation of femur to tibia PCL: prevent tibia posterior translation to femur

  30. Injury of Meniscus 1.Type I col Component: collagen: radially, longitudinally or circumferential Longitudinal fiber –dispersion hoop stress Radial ,longitudinal fib --- indure compressive force 2.Proteoglycans: absorb energy

  31. Medial meniscus • C- shaped structure: bigger than LM • Big Posterior Horn • Most of weight loading transmit to posterior horn • Whole peripheral border : firmly attached to the medial capsule and through the coronary ligament to the upper border of the tibia

  32. Lateral meniscus • More circular in form , thicker inperiphery • Covering up to 2/3of the articular surface of the tibia plateau • Ant. Horn: attached to the tibia medially in front of intecondylar eminance • Post. Horn: inserts into the post aspect of the intercondylar eminence and in front of the posterior attachment of the medial meniscus • Ligament of Wrisberg and ligament of Humphry • Tendon of popliteus: enveloped in a synovial membrane forms an oblique groove on the lateral border of the meniscus

  33. Function of Meniscus 1.Provision of stability 2.Shock absorption 3.Provision of increased congruity 4.Aids lubrication 5.Prevents synovial impingement 6.Limits extremes of flexion & extension 7.Tranmits loads across the joint --50% to 100% of load is transmitted through the menisci 8.Reduce contact stresses

  34. Physiologic condition • Lateral meniscus carries most of the load in the lateral compartment • Medial meniscus and the exposed articular cartilage shares the load almost equally in medial compartment

  35. Blood circulation • Blood capillary supply: periphery 1/3 of the menisc • Diffusion from the joint fluid: inner 2/3 The thickest central part of the meniscus farthest from the nutritional pathways is prone to degeneration

  36. Predisposing factor of meniscus injury • Peripheral cystic formation • Limited mobility by prejury or knee pathy • Congenial anomaly : discoid meniscus • Degeneration • Abnormal mechanical axis in joint with incongruity • Congenital relaxed joint • Inadequate musculature

  37. Injury of meniscus Mechanism: internal rotation of femur to tibia Type : 1) Longitudinal tear 2) Transverse tear 3) Horizontal tear 4) Others Symptom: 1)pain, tenderness(joint line tenderness) 2) limitation of motion (extension disability) 3) Locking: sudden extension limitation 4)giving way 5) Quadriceps atrophy (esp: Vastus medialis)

  38. Menisci tear

  39. Menisci tear in MRI • Double PCL sign • Vacant sign of medial joint space • Central displacement of the fragment • Flipped meniscus MRI: Sensitivity 93% Specificity 84% Fig

  40. Physical Exam: 1)Mcmurray test medial meniscus tear: tibial ext. rotation+adduction lateral meniscus tear: tibial int. rotation + abduction 2)Apley test; distaction test: ligament inj. glinding test: meniscus inj. 3)Squatting test: Dx.:Athrogram, MRI , Athroscope Tx. • Conservative Tx.: splint, NSAID, quadriceps exercise • Operative Tx.: athroscopicmenisectory(partial , total) athroscopicmeniscal repair, open menisectomy

  41. Indication of Meniscus repair 1. Vertical longitudinal tear 2. Above 1cm unstable tear 3. Normal condition of neighbouring 4.Vasculor zone tear: MM 30%, LM 25% 5. Under 40yrs , active

  42. Structure of protect in repair 1.MM: Sartorial branch of femoral nerve infrapatella branch of Saphenous nerve :flexon of knee 5—15degree 2.LM：peroneal nerve：flexion 90degree， figure-fourposition 3. Post. Horn：poplitel artery & vessel

  43. Meniscal suture technique • Anterior horn: out side to inside technique • Mid portion: Inside to outside technique • Posterior horn: All inside technique

  44. Discoid meniscus - most in lateral meniscus - unexplained - over exercise & thickening -> tear Meniscal cyst - young age , lateral meniscus - knee extension: palpable a lateral knee mass flexion : not palpable

  45. Tibial collateral ligment External rotation beyond 45°-> disruption of the medial capsular lig. External rotation beyond 45°+abduction -> disruption of the tibial collaterl lig. External rotation beyond 45°+abductjion after the tibial collateral lig. Is torn -> disruption of the ant. Cruciate lig. *Unhappy triad of O’Donoghue: ext.rot. + abd. : MCL ruption + medial meniscus injury + acl tear DX.: Stress test : 30° flexion knee and valgus stress Stress roentgenogrphy: when stress test checking AP X-ray < 5 mm: mild, 5-10mm: moderate , >10mm: severe

  46. Tx.: mild: elastic bandage, cast splint, cylinder cast (3-4weeks) Moderate: long leg cast Severe: early operation

  47. Lateral collatral ligament Tibia int. rotation + varus stress +stumble forward The frequency : low Severe : Iliotibial band, PCL, ACL, Peroneal nerv

  48. Anterior cruciate ligament Instability : full extension: ACL, PCL , MCL, LCL Flexion: ACL, PCL Acl= AM band + PL band Extension: AM , PL Flexion: only AM Most relaxed at flexion 40-50°with rot. -> tension Tear site : middle bundle > femoral attachment > tibia attachment Combined : LM or MCL tear ↑

  49. Mechanism: 1> External rotation & abduction with knee 90 ° flexion 2> Complete dislocation of the knee joint 3>Direct posterior force against the uper end of the tibia. 4>Internal rotation of the tibia while the knee is extended. Sx.: Pop sensation, hemorrhage, swelling Test; 1)anterior drawer test 2)Lachman’s test: 3)Pivot shift test, Mcintosh test, Slocum test ,losee test Dx.: PE, MRI, Athroscopic exam Tx: - conservative: brace cast, muscle strengthening exercise - surgery: bone-patella tendon-bone complex, semitendinosus, iliotibial band, allo graft

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