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Goldstein Shoulder Sport Medicine Flashcards

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1
Q

Indications for MRI in shoulder pathology (3)

A
  • Persistent symptoms despite nonoperative management
  • Mechanical symptoms
  • History of trauma with physical exam concerning for intraarticular pathology
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2
Q

Risk factors for adhesive capsulitis

A
  • Female gender
  • Age > 40
  • Trauma
  • Immobilization
  • Diabetes
  • Hypothyroidism
  • Cervical spondylosis
  • Stroke
  • Autoimmune disease
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3
Q
  1. Stages of adhesive capsulitis (Neviaser) (4)
A
  • Stage 1 (0-3 months)
    o Pain with active and passive ROM
    o Limitation of forward flexion, abduction, internal rotation, external rotation
    o Examination with the patient under anesthesia: normal or minimal loss of ROM
    o Arthroscopy, Diffuse glenohumeral synovitis, often most pronounced in the anterosuperior capsule
  • Stage 2 (“Freezing Stage”: 3-9 months)
    o Chronic pain with active and passive ROM
    o Significant limitation of forward flexion, abduction, internal rotation, external rotation
    o Examination with the patient under anesthesia: ROM essentially identical to ROM when the patient is awake
    o Anthroscopy: Diffuse, pedunculated synovitis (tight capsule with rubbery or dense feel on insertion of trochar
  • Stage 3 (“Frozen Stage”: 9-15 months)
    o Minimal pain except at end ROM
    o Significant limitation of ROM with rigid “end feel”
    o Examination with the patient under anesthesia: ROM identical to ROM when patient is awake
    o Arthroscopy: No hypervascularity seen, remnants of fibrotic synovium can be seen.
  • Stage 4 (“Thawing Stage”: 15-24 months)
    o Minimal pain
    o Progressive improvement in ROM
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4
Q
  1. Imaging findings of adhesive capsulitis (3)
A
  • Disuse osteopenia
  • Obliteration of the axillary pouch on MRA
  • Lack of filling of biceps sheath on MRA
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5
Q
  1. Treatment options for adhesive capsulitis (6)
A
  • Education
  • NSAIDs
  • Intraarticular steroid injections
  • Physiotherapy (modalities, gentle stretching, hydrotherapy)
  • Manipulation under anaesthesia
  • Arthroscopic release
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6
Q
  1. Contraindications to MUA for adhesive capsulitis (5)
A
  • Osteopenia
  • Neurologic disorder
  • Recent surgery about the shoulder
  • Recent fracture
  • Instability of the shoulder
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7
Q
  1. Technique of MUA for adhesive capsulitis (9)
A
  • Stabilize scapula
  • Grasp humerus just above the elbow
  • Externally rotate in adduction
  • Abduct in the coronal plane
  • Externally rotate in abduction
  • Internally rotate in abduction
  • Flex the shoulder
  • Return to adduction
  • Internally rotate
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8
Q
  1. Technique of arthroscopic release of adhesive capsulitis (10)
A
  • Examination under anaesthesia
  • Diagnostic arthroscopy
  • Complete synovectomy
  • Rotator interval capsular release (inferior to biceps to just superior to subscapularis)
  • Examination under anaesthesia
  • Capsular release deep to subscapularis to 5 o’clock (if deficient ER in adduction)
  • Examination under anaesthesia
  • Posterior capsular release adjacent to labrum (if deficient ER in abduction)
  • Examination under anaesthesia
  • Interscalene block and commencement of CPM
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9
Q
  1. Factors contributing to glenohumeral joint stability (5)
A
  • Bony architecture
  • Glenoid labrum
  • Negative intra-articular pressure
  • Glenohumeral ligaments
  • Concavity compression
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10
Q
  1. Shoulder dislocation associated injuries (4)
A
  • Bankart lesion (bony or soft tissue)
  • Hill Sachs lesion
  • Axillary nerve injury
  • Rotator cuff tear
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11
Q
  1. Types of shoulder instability (3)
A
  • Acute vs. chronic
  • Unidirectional (TUBS) vs. multidirectional (AMBRI)
  • Anterior vs. posterior
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12
Q
  1. Etiology of multidirectional shoulder instability (4)
A
  • Poor shoulder proprioception
  • Weak rotator cuff
  • Weakness/asynchrony of scapular stabilizers
  • Generalized ligamentous laxity
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13
Q
  1. Signs of generalized ligamentous laxity (5)
A
  • Elbow hyperextension
  • Wrist hyperflexion
  • MCP hyperextension
  • Genu recurvatum
  • Palms to floor
  • (Proximal → distal)
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14
Q
  1. Physical exam tests for instability of the shoulder (4)
A
  • Sulcus sign
  • Load and shift (anterior-posterior translation
  • Apprehension-relocation-surprise
  • Posterior jerk test
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15
Q
  1. Nonoperative treatment options for multidirectional shoulder instability (3)
A
  • Activity modification
  • NSAIDs
  • Physiotherapy
    o RC strengthening
    o Scapular stabilizer strengthening
    o GH proprioception
    o Gradual return to activity
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16
Q
  1. Indications for surgical treatment of shoulder instability (4)
A
  • 1st time traumatic dislocation in a young, high-level athlete (?)
  • Recurrent instability following traumatic dislocation
  • Multidirectional instability despite appropriate course of nonoperative treatment
  • Pain, instability, neurologic symptoms with ADLs
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17
Q
  1. Possible indications for open treatment of acute anterior shoulder instability (4)
A
  • Bony Bankart ≥ 25% of glenoid face
  • Large engaging Hill-Sachs defect
  • Generalized ligamentous laxity
  • Recurrent instability
  • Significant capsular stretching
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18
Q
  1. Relative contraindications to surgical treatment of shoulder instability (3)
A
  • Generalized ligamentous laxity
  • Connective tissue disorders
  • Voluntary dislocators
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19
Q
  1. Principles of open treatment of anterior shoulder instability (5)
A
  • Deltopectoral approach
  • Humeral-based T-capsulotomy
  • Repair of labral injuries or ORIF bony bankart lesions
  • Treatment of Hill Sachs lesion
  • Inferior capsular shift (north-south capsular plication)
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20
Q
  1. Principles of arthroscopic anterior shoulder stabilization (9)
A
  • Examination under anaesthesia
  • Diagnostic arthroscopy
  • Treat associated intraarticular pathology
  • Labral repair
  • Probe to confirm repair
  • ROM to determine if Hill Sachs lesion engages/instability remains
  • Treat Hill Sachs lesion
  • Postoperative immobilization
  • Supervised rehabilitation
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21
Q
  1. Principles of arthroscopic treatment of multidirectional instability (9)
A
  • Examination under anaesthesia
  • Diagnostic arthroscopy
  • Treat associated intraarticular pathology
  • Posterior labral repair/capsular plication (posterosuperior portal)
  • Anterior labral repair/capsular plication
  • Close the rotator interval if necessary (MGHL → SGHL)
  • Close the posterior portal
  • Postoperative immobilization
  • Supervised rehabilitation
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22
Q
  1. Options for treatment of a reverse Hill-Sachs defect (7)
A
  • Reduction and cancellous bone grafting (so-called anatomic reconstruction)
  • McLaughlin procedure – subscapularis advancement into the defect
  • Lesser tuberosity advancement into the defect (Neer modification of the McLaughlin procedure)
  • Bone grafting with size-matched humeral head allograft
  • Proximal humerus rotational osteotomy
  • Humeral head resurfacing
  • Arthroplasty
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23
Q
  1. Shoulder instability repair postoperative protocol (4)
Study These Flashcards
A
  • Immobilization for 6 weeks
  • Progressive PROM → AAROM → AROM
  • RC/scapular stabilizer strengthening at 3 months
  • Return to sports at 6 months
24
Q
  1. Causes of a failed shoulder stabilization (6)
Study These Flashcards
A
  • Missed HAGL lesion
  • Rotator cuff tear
  • SLAP tear
  • Engaging hill Sachs/humeral bone loss
  • Glenoid loss
  • Hardware failure
25
31. Positive prognostic factors for surgical treatment of acute anterior shoulder instability (5)
- Age < 25 years - Acute Bankart lesion - Hemarthrosis - Good soft tissue quality - Lack of significant capsular stretching
26
32. Decision-making factors for treatment of chronic shoulder dislocation (6)
- Functional limitations - Presence or absence of pain - Duration of dislocation - Size of bony defect of humeral head - Presence of glenoid bone erosions - Status of the articular cartilage
27
33. Poor prognostic factors for posterior shoulder dislocation (6)
- Late diagnosis - Large humeral head impression defect - Presence of secondary humeral head deformity and arthrosis - Concomitant proximal humeral fracture - Closed reduction is not successful - Arthroplasty is required
28
35. Mechanisms of injury for SLAP tears (4)
- Direct compression loads (FOOSH, direct blow to an adducted humerus) - Forceful traction loads - Repetitive overhead throwing activities - Sudden forced abduction/ER
29
36. Classification of SLAP tears (Snyder) (7)
- Type I: superior labral fraying/degeneration - Type II: (#1) detachment of superior labrum with biceps anchor - Type III: bucket-handle tear of the labrum with intact biceps anchor - Type IV: bucket-handle tear with extension into the biceps tendon - Type V – SLAP with a Bankart - Type VI – SLAP with an unstable flap tear of labrum - Type VII – SLAP with continuation to the origin of the MGHL
30
37. Physical exam tests for SLAP lesions (4)
- Speed’s test - Yerguson’s test - O’Brien’s active compression test - Anterior slide test
31
38. MRA findings consistent with a type II SLAP tear (3)
- Contrast under the superior labrum/biceps anchor on coronal images - Laterally curved high-signal intensity in superior labrum - Concomitant anterosuperior labral pathology - Anterosuperior extension of high signal at superior labrum/biceps root on axial images
32
39. Nonoperative management of SLAP tears (4)
- Activity modification - NSAIDs - Physiotherapy (posterior capsular stretching, RC/scapular stabilizer strengthening) - Retraining of throwing mechanics as needed
33
40. Indications for surgical treatment of SLAP tears (3)
- Failure of ≥ 3 months of nonoperative management - Evidence of associated suprascapular nerve compression
34
41. Principles of arthroscopic repair of SLAP lesion (9)
- Examination under anaesthesia - Diagnostic arthroscopy (probe labrum, peel-back test) - Treat associated intraarticular pathology - Prepare superior glenoid - Decompress associated suprascapular notch cysts as needed - Suture anchor fixation of labrum - Reprobe, repeat peel-back test - Post-op immobilization - Supervised rehabilitation
35
42. Stages of impingement syndrome (Neer) (3)
- Stage 1: edema and hemorrhage - Stage 2: fibrosis and tendinosis - Stage 3: bone spurs and tendon rupture
36
43. Classification of acromion morphology (Bigliani) (3)
- Type I: flat - Type II: curved - Type III: hooked
37
44. Components of pathogenesis of rotator cuff tears (4)
- Genetic predisposition - Intrinsic degenerative changes - Trauma - Extrinsic impingement from surrounding structures
38
45. Histopathologic changes of degenerative rotator cuffs (4)
- Hypoxic degenerative tendinopathy - Mucoid degeneration - Tendolipomatosis - Calcifying tendinopathy
39
46. Natural history of rotator cuff tears
- 50% of asymptomatic tears become symptomatic in 5 years - 50% of partial thickness tears enlarge - 25% of partial thickness tears progress to full-thickness tears - (Good → bad)
40
47. Special tests for rotator cuff tears (7)
- Empty-can test (supraspinatus) - Resisted ABER (infraspinatus) - Resisted ER in adduction (infraspinatus/teres minor) - Belly press (subscapularis) - Lift off (subscapularis) - Drop-arm test - Hornblower’s sign
41
48. Classification of partial thickness RC tears (Ellman) (10)
- **A – articular sided** o Grade 1: < 3 mm o Grade 2: 3-6 mm o Grade 3: > 6 mm - **B – bursal sided** - **C – intratendinous** - **Combined**
42
49. Components of nonoperative treatment of partial thickness RC tears (4)
- Activity modification - NSAIDs - Subacromial steroid injection - Physiotherapy (modalities, ROM, RC/scapular stabilizer strengthening)
43
50. Indications for surgical treatment of partial thickness RC tears
- Failure of appropriate nonoperative management - Acute traumatic tears - Bursal-sided tears - Tears in physically active patients
44
51. Required releases for repair of massive rotator cuff tears (5)
- Subacromial and subdeltoid adhesions with excision of bursal tissue - Release of deep adhesions of supraspinatus and infraspinatus from capsule and labrum - Release of the rotator interval including coracohumeral ligament - 360° release of subscapularis from coracoid, conjoined tendon, axillary nerve and circumflex vessels, capsule and glenoid neck (if involved) - Posterior interval slide between supraspinatus and infraspinatus
45
52. Factors associated with a poorer outcome following surgical treatment of RC tears (11)
- Increasing age (> 65) - Smoking - Worker’s compensation - Previous surgery - Preoperative weakness of ER and abduction - Increasing duration of tear - Larger tear size/multitendon tears - Fatty infiltration > 50% - Tendon retraction > 5 cm - Proximal humeral head migration/anterosuperior escape (AH distance < 7 mm) - Chronic biceps tendon rupture - (Patient, tear)
46
53. Grading of fatty infiltration of rotator cuff muscles (Goutallier) (5)
- Grade 0: no fat - Grade 1: some fatty streaks - Grade 2: more muscle than fat - Grade 3: equal muscle and fat - Grade 4: less muscle than fat
47
54. Negative prognostic factors for outcome after latissimus dorsi transfer for massive RC tears
- Female sex - Preoperative elevation < 90° - Weakness of forward flexion - Complete loss of ER - Superior escape - Subscapularis tear - Being performed as a staged procedure (rather than when RC is identified as irreparable) - (Patient, injury, surgery)
48
55. Radiographic findings of rotator cuff arthropathy (5)
- Superior migration of the humeral head - Acetabularization of the coracoacromial arch - Acromial sclerosis - Femoralization of the proximal humerus (loss of head-GT contour - GT cysts
49
56. Contraindications to shoulder arthroplasty (5)
- Deltoid and rotator cuff both nonfunctional - Active infection - Neuropathic arthropathy - Non-compliant patient - Intractable instability
50
57. Contraindications to glenoid resurfacing in TSA (2)
- Inadequate glenoid bone stock - Rotator cuff deficiency
51
58. Criteria for performance of a rTSA in rotatory cuff arthropathy (6)
- Intact glenoid bone stock - Normal bone density - Intact axillary nerve with a functioning deltoid - No active infection - Limited active elevation - Patient willing to accept low postoperative physical activity
52
59. Indications for shoulder arthrodesis (9)
- Painful ankylosis after infection - Stabilization of painful paralytic shoulder - Post-traumatic brachial plexus palsy - Arthritis in patients with contraindications to arthroplasty - Massive irreparable RC tears with arthropathy and nonfunctional deltoid - Recurrent instability - Neuropathic arthropathy - Salvage of failed shoulder arthroplasty - Tumor resection
53
60. Contraindications to shoulder arthrodesis (5)
- Patient wants motion - Active infection - Ipsilateral elbow fusion - Contralateral shoulder fusion - Charcot arthropathy
54
61. Technique of shoulder arthrodesis (4)
- Posterior incision along spine of scapula curving distally along proximal humerus - Split posterior deltoid and capsule - Denude glenoid and humeral head of articular cartilage - Precontoured plates (2) from spine of scapula/acromion to humerus (one lateral, one posterior)
55
62. Causes of long thoracic nerve injury and medial scapular winging (5)
- Closed trauma - Direct compression - Traction/stretching injury - Direct blow - Viral infection (Parsonage-Turner syndrome)

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