joint injury

1. Affection shoulder

2. Affection knee

3. Affection elbow

4. Affection hip

Affections of shoulder I. 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.

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> 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

II. Biomechanics glenohumeral motion

scapulothorcic motion

eg) abduction 180°= gelnohumeral motion 90 - 110° + scaulothoracic motion 70-90 °

*clavicle motion: 40-60 °

III. Thoracic outlet syndrome

1> cervical rib syndrome

2> scalenus anticus syndrome

3> costoclavicular syndrome

4> hyperabduction syndrome

anatomy

upper middle lower

1>scalenus anticus 2>scalenus medicus 3>1st rib

1>1st rib2> clavicle

1> coracoid process2> pectoralis minor3>coracoid membrane

1. Cervical rib syndrome-characteristics: from 7th cervical spine

-anatomy: 1>bone or fibrous band

2>brachial plexus &subclavian a. -> over cervical 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

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

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

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):

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

• Subacromial space:

• Subacromial bursa:

• Subteltoid bursa:

IV. Subacromial Syndrome

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

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° 이상의전범위 )

2.BursitisSubacromial 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

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

Stage of impingement syndrome

Stage I Stage II Stage III

Pathology :

Typical age:Clinical course:

Treatment:

Edema &Hemorrhage<25 YrReversible

Conservative

Fibrosis &Tendinitis25-40 YrRecurrant pain with activity Consider operation

Bonspur &Tendon rupture >40 YrProgressive disability Ant. Acromioplasty &rotator curr repair

Mechanism :1. Upper limb abduction

2. Supraspinatus clipping between humerus great tubercle & acromion

3. With increasing age the protection of the bursa was weak, ongoing trauma due to mechanical stimulation and inadequate recovery

4. Supraspinatus early wear, local ischemia, inflammation, calcification

*Dawbarn’s sign: pain at humerus great tubercle

painless when complete abduction-> bursa placed at sub acromion.

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

Tx.1. Conservativ Tx.

2. Operative Tx. : after conservative Tx 3Ms, still have symptom.

1) ant. acromioplasty

4.Rupture of supraspinatus tendon

- Trauma history- Degenary change : essential prerequisite rupture

- Partial tear : self healing possible

Complete tear (x)

- 45-65 yrs

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

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.

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.

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

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

Trigger Fignger & ThumbCharac: 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

Avascular necrosis of the hip1.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 defect3.Male : female = 3:14.Sclerosis and lucency, Subchondral fracture

(Cresent sign)5.Core decompress, living bone graft, rotational

osteotomy, arthroplasty

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

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

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

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

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

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

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

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

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)

Menisci tear

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

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. 1) Conservative Tx.: splint, NSAID, quadriceps exercise

2) Operative Tx.: athroscopic menisectory(partial , total) athroscopic meniscal repair, open menisectomy

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

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-four position

3. Post. Horn ： poplitel artery & vessel

Meniscal suture technique

• Anterior horn: out side to inside technique

• Mid portion: Inside to outside technique

• Posterior horn: All inside technique

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

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

Tx.:

mild: elastic bandage, cast splint, cylinder cast (3-4weeks)

Moderate: long leg cast

Severe: early operation

Lateral collatral ligament

Tibia int. rotation + varus stress +stumble forward

The frequency : low

Severe : Iliotibial band, PCL, ACL, Peroneal nerv

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

↑

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

Posterior cruciate ligment injury Basic stabilizer of knee, prevent hyperextension, prevent posterior tranlation &

int rotation of tibia when knee flexion, prevent varus and valgus angulation at knee extension

Composed : anterolateral &posteromedial band

Tensioning: flexion : anterior portion extension: posterior

Mechanism:

1) severe rotational injury: external rotation-valgus injury

or an internal rotation-varus injury

2) Hyperextension injuy:

3)Direct trauma to the upper tibia while the knee is flexed( posterior translation)

4)Complete dislocation

Osteochondritis dissecans

• OCD is caused by blood deprivation in the subchondral bone.

• This loss of blood flow causes the subchondral bone to die in a process called avascular necrosis. The bone is then reabsorbed by the body, leaving the articular cartilage it supported prone to damage.

• The result is fragmentation (dissecans) of both cartilage and bone, and the free movement of these osteochondral fragments within the joint space, causing pain and further damage

• joint pain in physically active adolescent

• Common reason of foreign body of joint

• Lateral wall of medial femur condyle

• Insidious onset, pain even at rest, and aggreviated by exercis

Recurrent dislocation of the patella

• Dislocation , subluxation

Sx.:

patellofemoral degenerative arthritis

Dx.:

Apprehension test:

Chondromalacia Patellae

• Softening of the articular cartilage

Sx.:Diffuse pain over the front or anteromdial aspect of the

knee made worse when the knee functions under load in flexion, such as when going up and down stairs.

Patella compression test: at knee fexion

Tx.: - avoiding stair climbing, keeping the knee fully extended while sitting and avoiding squatting

- Quadriceps resisitive exercise

Osgood-Schlatter’s disease

1. Sudden traction- > partial seperation

-> epiphysis of the tibial tuberosity

2. bilateral , 10-15 male

3.swelling, tenderness, pain at active knee extension

4.Xray: multiple fragmented area of ossification

ossification center of tubercle -> prolonged distally

5.Tx.: conservative Tx.

extension knee long leg cast, restriction of activity

Is there effusion?

Patellar Palpation/Tilt/Apprehension

Lachman

Valgus/Varus Stress

McMurray’s Test

Apley’s Test

Symptom: anterior ankle pain, swelling after activity, limited

dorsiflexionDx: Clinical , based on physical examination -local pain on palpation is present anteriorly,And osteophytes maybe palpable with ankle joint in slight

plantarflexion -pain on palpation is predominantly located

anteromedially – anteromedial impingement -pain on palpation is predominantly located

anterolaterally- anterolateral impingement X-ray: Ferkel view normal tibiotalar angle is 60 °or more angle less than 60 ° may indicate bony impingement

Tx:

conservative treat: resting, NSAIDS, injection, hill lifts

Surgery: Resection of osteophyte and inflamed soft tissue

--Tarsal and tibial osteophytes decrease anterior space, compression of soft tissue component is likely to occur

--Therefore important to remove these osteophytes restoring anterior space and reducing chance that symptoms recur

Painful heel syndrome

Proximal plantar fascitis Ankylosing spondylitis

sex F>M (2times) M>F (3times)

Age Average 45yrs 2nd &3rd decadeOnset after age 40 unusual

Tenderness Medial calcaneal tuberosity Tendon insertion site

Systemic Sx. None Back pain , uveitisAortic insufficiencyInflammatory disease etc.

Activity Pain aggravation relief

Heel spur (+) 50% (-)

Sx Firs step pain Morning stiffness

HLA –B27 (-) (+)

site Bilateral