Clinical Director, University of New Mexico School of Medicine
An anatomic repair places the tendon back to the bone to cover the entire original footprint of the tendon to bone symptoms neuropathy buy discount sustiva 200 mg. When these sutures are tied medications like prozac 200 mg sustiva, the tendon comes to the medial border of the greater tuberosity (B) medicine 72 hours 200mg sustiva amex. The suture ends are then pulled over the greater tuberosity to help compress the lateral edge of the greater tuberosity (C) medications known to cause hair loss generic sustiva 200 mg free shipping. Protection of the repair after surgery avoids active motion of the shoulder, specifically any lifting, reaching, pushing, or pulling for 6 to 12 weeks, depending on the size of the tear and the quality of the tissues and repair. During this time, there is protection of the shoulder in a sling or pillow brace to place the shoulder in approximately 20 degrees of abduction. Postoperative shoulder stiffness (frozen shoulder) is minimized by close postoperative evaluation of shoulder motion by the surgeon or other health care provider over the first 2 months after surgery. Starting with passive range of motion during the first 6 to 8 weeks from surgery, therapy is individualized based on the size of the tear, quality of the tissues and repair, and amount of stiffness that occurred over the first few weeks after surgery. With the location of the subscapularis muscle being posterior to the chest wall, its most significant function in internal rotation is seen with the arm closest to the body. Therefore, the function of the subscapularis muscle and its associated tendon is most responsible for the internal rotation function of the shoulder, particularly internal rotation strength near the center of the body. This important function specific to the subscapularis results in defining the most sensitive physical examination tests for weakness associated with this part of the rotator cuff. For these reasons the best method of testing for subscapularis function is to test internal rotation strength close to the Excessive passive external rotation of left side indicating trunk rather than away from the body. The abdominal detachment of the subcapularis tendon compression test or internal rotation lag sign are the two best methods for testing subscapularis function. Most subscapularis tendon tears will be missed on physAbdominal compression test ical examination if these specific subscapularis tests are not performed, and internal rotation strength is tested in various degrees of abduction and external rotation Consistent with loss of because the other internal rotators of the shoulder are subscapularis tendon so strong that the less specific physical examination attachment to the left tests will not show weakness by manual muscle testing. Patent unable inability to internally rotate the arm with the hand to internally rotate the against the abdomen with or without resistance to arm and place the elbow internal rotation. Elevation of the palm off of the abdomen to achieve some internal rotation of the shoulder is a sign of weakness of the subscapularis. This is necessary to rule out is a result of weakness, not loss of passive range of motion. Another test for subscapularis function is the lift-off or internal rotation lag sign. This test is more difficult for many patients to do because of shoulder pain, and rotation, there is an increase in passive external rotation this subscapularis tendon tear is associated with a disit requires good passive range of motion and normal because of loss of the continuity of the subscapularis location in the long head of the biceps tendon from the elbow function. For these reasons, this test is not always muscle and tendon to the lesser tuberosity. Repairs can be done by either open or performed in patients with larger rotator cuff tears. The principles and this test is more sensitive to define minor weakness of the patient is placed in the supine position and each methods of repair are the same as those described for supraspinatus and infraspinatus tears. Long head of the the rotator cuff associated with smaller or partial tears, shoulder is passively externally rotated and compared. Acute traumatic full-thickness subscapularis tears are biceps damage or dislocation is treated by release of the and in these cases most patients are able to perform this test. With subscapularis tendon tears described in the discussion of pathologic processes of the buttock. In addition to a loss of active internal there is often damage to the long head of the biceps. It may be associated with inflammatory changes of the joint, but the damage to the cartilage is not primarily based on an inflammatory pathologic process as it is for rheumatoid arthritis. The rotator cuff tendons are almost always intact in patients with osteoarthritis, and there is a proliferative osteophyte formation around the periphery of the humeral head, making it much larger than normal. The joint enlargement and flattening of the humeral head results in loss of motion. There is loss of the uniformly white articular cartilage on the surface of the humeral head, and there is proliferation of bone (osteophyte) along the periphery of the humeral head. In most cases of osteoarthritis, the humeral head is well centered within the center of the glenoid in anteroposterior radiographs. This is defined as the center of the humeral head being close to the midline of the center of the glenoid. Another method of assessing this alignment is a smooth and continuous scapulohumeral line at the inferior part of the humeral neck (Maloney line). A continuous Maloney line is not seen when the rotator cuff is damaged, as seen on the anteroposterior radiographs in rotator cuff tear arthropathy (see Plates 1-49 and 1-50. With large and massive rotator cuff years there is superior migration of the humeral head with narrowing of the subacromial space. The more advanced pathologic changes are more difficult to correct with joint replacement. The clinical findings of advanced osteoarthritis are significant loss of passive (stiffness) and active (pain-related) glenohumeral motion. Significant pain in the shoulder is typically along the anterior and posterior joint line with deep palpation.
Muscle attachments Origins Insertions Deltoid muscle Supraspinatus muscle Levator scapulae muscle Rhomboid minor muscle Infraspinatus muscle Teres minor muscle Rhomboid major muscle Infraspinatus muscle Latissimus dorsi muscle (small slip of origin) Triceps brachii muscle (long head) Teres minor muscle Teres major muscle Triceps brachii muscle (lateral head) Deltoid muscle Brachialis muscle the large deltoid muscle has its broad origin from the spine of the scapula posteriorly around the lateral acromion and then from the lateral third of the clavicle treatment 1st line buy 600mg sustiva. Likewise medicine queen mary buy sustiva 200 mg with mastercard, the trapezius muscle takes its insertion over a very similar area superior and medial to the deltoid origin symptoms strep throat purchase genuine sustiva. The trapezius has its primary function in scapula retraction and elevation of scapula symptoms in dogs generic sustiva 200 mg visa. The deltoid origin on the humerus at the deltoid tuberosity is approximately one third the distance from the shoulder to the elbow. The levator scapulae and rhomboid major and minor insert on the medial border of the scapula and function to retract the scapula toward the spine. Between the anterior portion of the scapula and the chest wall (not shown) is the scapulothoracic articulation. Bony and soft tissue pathologic processes can result in bursitis and possibly crepitus at this articulation, leading to a "snapping scapula. The dorsum is convex and is separated by the prominent spinous process into a supraspinatous fossa above, for the supraspinatus muscle, and an infraspinatous fossa below, for the infraspinatus muscle. The suprascapular notch is immediately medial to the coracoid process at the superior aspect of the scapular body. The spinous process is a large triangular projection of the dorsum of the bone, extending from the medial border to just short of the glenoid process. It increases its elevation and weight as it progresses laterally and ends in a concave border, the origin of which is the neck of the scapula. The spinous process continues freely to arch above the head of the humerus as the acromion, which overhangs the shoulder joint. Its lateral surface provides origin for the posterior and middle thirds of the deltoid muscle. The coracoid process projects anteriorly and laterally from the neck of the scapula. It gives attachment to the pectoralis minor, the short head of the biceps brachii, the coracobrachialis, the coracoacromial ligament, and the coracoclavicular ligaments. The lateral angle of the scapula broadens to form the glenoid, which has minimal bony concavity. The fibrocartilaginous glenoid labrum attaches circumferentially to the margin of the glenoid, and the long head of the biceps brachii attaches directly to the supraglenoid tubercle. Proximally, the head is roughly one third of a sphere, although the anteroposterior dimension is slightly less than the superoinferior distance. The surgical neck is the narrowed area just distal to the tubercles, where fractures frequently occur. The greater tubercle serves as the attachments for the supraspinatus, infraspinatus, and teres minor tendons. Each of the tubercles is prolonged downward by bony crests, with the crest of the greater tubercle receiving the tendon of the pectoralis major muscle and the crest of the lesser tubercle receiving the tendon of the teres major muscle. The intertubercular groove, lodging the long tendon of the biceps brachii muscle, also receives the tendon of the latissimus dorsi muscle into its floor. The shaft of the humerus is somewhat rounded above and prismatic in its lower portion. The deltoid tuberosity is prominent laterally over the midportion of the shaft, with a groove for the radial nerve that indents the bone posteriorly, spiraling lateralward as it descends. When viewed from above, the clavicle has a gentle S shape with a larger medial curve that is convex anteriorly and a smaller lateral curve that is convex posteriorly. The medial two thirds of the bone is roughly triangular in section, whereas the lateral third is flattened. The undersurface of the lateral third of the bone demonstrates the conoid tubercle and trapezoid line, which correspond to the attachment of the two parts of the coracoclavicular ligament. The sternal extremity of the bone is triangular and exhibits a saddle-shaped articular surface, which is received into the clavicular fossa of the manubrium of the sternum. The acromial extremity has an oval articular facet, directed lateralward and slightly downward, for the acromion. Costoclavicular ligament Coracoclavicular ligament Trapezoid ligament Conoid ligament Posterior Subclavius muscle Sternohyoid muscle In addition to functioning as a strut that keeps the shoulder in a more lateral position, it also serves as a point of attachment for several muscles. Medially, the clavicular head of the pectoralis major originates anteriorly while the sternohyoid muscle originates posteriorly. The subclavius muscle originates from the inferior surface of the middle third of the clavicle. Laterally, the anterior third of the deltoid originates anteriorly, a portion of the sternocleidomastoid originates superiorly, and a portion of the trapezius inserts posteriorly. Resection of portions of the clavicle is typically well tolerated as long as the integrity of the muscular attachments is not compromised. Rotation of the clavicle at this joint allows the arm to be placed in an over-the-head position. An articular disc is interposed between the joint surfaces, which greatly increases the capacity for movement. The superior, middle, and inferior glenohumeral ligaments are thickenings in the anterior wall of the articular capsule. Really visible only on the inner aspect of the capsule, they radiate from the anterior glenoid margin adjacent to and extending downward from the supraglenoid tubercle of the scapula. It has an oblique course immediately inferior to the opening of the subscapular bursa. When present, the middle glenoid humeral ligament inserts on the glenoid rim posterior to the labrum.
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A depression is formed beneath the clavicle between the coracoid prominence of the shoulder and the lateral clavicular origin of the pectoralis major muscle medications guide discount generic sustiva canada. The axillary artery is most superficial within this depression and can be easily palpated symptoms dizziness nausea sustiva 200mg discount. To follow the courses ofthe remainder of the vessel symptoms mono buy 200 mg sustiva, it is necessary to unfold the muscular envelope and view the artery in its anatomic context medicine 6 year course buy discount sustiva 200 mg. Along this span, the artery lies within a cleft formed by muscles originating on the scapula. The broad subscapularis, converging toward the head of the humerus, forms the majority ofthe posterior bed on which the vessel lies. The lowest segment of the artery crosses the teres major and latissimus dorsi insertions. The medial wall of the cleft consists of the serratus anterior, wrapping around the upper nos from its origin on the medial border of the deep scapular surface. The coracoid process arches over the axillazy neurovascular bundle and gives origin to muscles that lie anterior to the vessels. One of these, the pectoralis minor muscle, is used as a landmark to divide the axillary artery into three parts which are medial to , behind, and lateral to the muscle. The coracobrachialis, a small muscle analogous to the adductors of the thigh, and the short head of the biceps brachii also originate from the tip ofthe coracoid process. The pectoralis major adds the final anterior blanket of muscle over the axillary space. Immediately after passing over the outer rim of the first rib, the axillary artery gives origin to the small supreme thoracic artery. Behind the medial margin of the pectoralis minor muscle, the second part of the axillary artery gives rise to the thoracoacromial artery from its anterior surface and the lateral thoracic artery from its inferior surface. After penetrating the clavipectoral fascia, the thoracoacromial artery divides into lateral acromial and deltoid branches, and medial clavicular and pectoral branches. The pectoral branch, with its accompanying vein and lateral pectoral nerve, forms the major neurovascular pedicle to the pectoralis major muscle. The latter is joined by the thoracodorsal nerve to form the principal neurovascular pedicle of the latissimus dorsi muscle. Theremaining two branches of the distal axillazy artery are the medial and lateml humeral circumflex arteries. The lateral bnmcb, w;companied by the axillary nerve, passes between the teres major, teres minor, long head ofthe triceps, and the humerus to reach the posterior aspect ofthe shoulder. Several important branches arise from the roots, trunks, divisions, and cords of the brachial plexus and traverse the axillary space. The nerve of the axilla with the most proximal origin is the long thoracic arising from the ventral primary rami of cervical nerves three, four, and five. It lies relatively far posterior in the serratus/subscapularis cleft described above. The lateral and medial pectoral nerves are named for the cords of the brachial plexus from which they arise. Anatomically, they occupy relative positions opposite to what their names imply and have been described in clinical literature by positional designations. The pectoral nerves are important because they innervate the large pectoralis muscle. The lateral pectoral nerve usually divides into two to four branches and supplies the cephalad portion of the pectoralis major muscle. The branches that join the pectoral branch of the thoracoacromial artery form a neurovascular pedicle on which the pectoralis muscle can be transplanted. The medial pectoral nerve passes between the axillary artery and vein, penetrates and supplies the pectoralis minor muscle, and continues through that muscle as one or more branches to supply the caudal part of the pectoralis major muscle. The musculocutaneous nerve arises from the lateral cord and supplies the coracobrachialis, biceps brachii, and the medial part of the brachialis muscles. The medial antebrachial and brachial cutaneous nerves arise from the medial cord in the midaxilla. The latter is usually joined by the intercostobrachial nerve spanning the distal axillary space from the second intercostal nerve. The thoracodorsal nerve arises from the posterior cord and joins the thoracodorsal artery to the latissimus d<mi muscle. The subscapular nerves to the subscapularis and teres major muscles also arise from the posterior cord. The last branch of the posterior cord is the axillary nerve to the teres minor and dehoid muscles and posterior shoulder. The three major nerves to the upper extremity, the median, ulnar, and radial, surround the distal I. The radial nerve deviates from the neurovascular bundle at the distal border ofthe latissimus tendon and passes posteriorly around the humerus with the deep brachial artery. The central compartment of the axilla is occupied by the neurovascular bundle and loose, fatty, areolar tissue containing lymphatics and lymph nodes. The neurovascular bundle is surrounded by a fascial wrapping called the axillary sheath. Vascular and nerve branches exit the sheath and traverse the fatty axillary contents to reach their destinations. The bulk of the fatty axillary content is anterior, caudal, and posterior to the sheath. There is a clear plane between the sheath and fat along the anterior surface of the axillary vein. This plane is used to identify the neurovascular branches when beginning an axillary dissection.
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