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:
2> extension:
3> abduction:
1) ant. Fiber of deltoid
2) coracobrachialis
1) latssimus dorsi
2) teres major
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 rib
2> clavicle
1> coracoid process
2> pectoralis minor
3>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
IV. Subacromial Syndrome
• Subacromial space:
• Subacromial bursa:
• Subteltoid bursa:
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°이상의 전범위)
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
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
Pathology :
Typical age:
Clinical
course:
Edema &
Hemorrhage
<25 Yr
Reversible
Conservative
Treatment:
Stage II
Stage III
Fibrosis &
Tendinitis
25-40 Yr
Recurrant pain
with activity
Consider
operation
Bonspur &
Tendon rupture
>40 Yr
Progressive
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
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 & 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
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
Anatomy
Affections of Knee
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 loa
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; contr
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.:
Tx:
PE, MRI, Athroscopic exam
- 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
dorsiflexion
Dx: 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 decade
Onset after age 40
unusual
Tenderness
Medial calcaneal tuberosity
Tendon insertion site
Systemic Sx.
None
Back pain , uveitis
Aortic insufficiency
Inflammatory disease etc.
Activity
Pain aggravation
relief
Heel spur
(+) 50%
(-)
Sx
Firs step pain
Morning stiffness
HLA –B27
(-)
(+)
site
Bilateral