Shoulder & Elbow Flashcards
(334 cards)
1
Q
Most common nerve injury from elbow arthroscopy?
A
Transient ulnar nerve palsy.
2
Q
Lateral elbow arthroscopy portals?
A
3
Q
For elbow arthroscopy what is the location of proximal anterolateral portal and nerve at risk?
A
1-2 cm proximal and 1 cm anterior to lateral epicondyle
Radial nerve. Risk decreases as portal moved more proximally.
4
Q
For elbow arthroscopy what is the distal anterolateral portal location and nerve at risk?
A
1 cm anterior and 1-3cm distal to lateral epicondyle
Radial nerve and lateral antebrachial cutaneous nerve.
5
Q
For elbow arthroscopy what is the location of direct lateral (mid-lateral) portal and nerve at risk?
A
“soft spot” portal (in triangle formed by olecranon, radial head, epicondyle)
relatively safe, lateral antebrachial cutaneous nerve
6
Q
Visualize medial elbow arthroscopy portals.
A
7
Q
In elbow arthroscopy what is the location of the anteromedial portal? What nerve is at risk?
A
2 cm anterior and 2cm distal to medial epicondyle.
Medial antrebrachial cutaneous nerve and median nerve.
8
Q
In elbow arthroscopy what is the location of the superiormedial portal? What sturcture is at risk?
A
2cm proximal to medial epicondyle, anterior to intermuscular septum.
Medial antrebrachial cutaneous nerve. Ulnar nerve 3-4mm away. Median nerve.
9
Q
In elbow arthroscopy location of the straight posterior portal?
Structures at risk?
A
3cm proximal to olecranon, triceps midline (musculotend. junction).
Posterior antebrachial cutanous nerve and ulnar nerve.
10
Q
In elbow arthroscpy what is an alternative that provides better posterior compartment visualization than the straight posterior portal?
A
Posterolateral -2-3 cm proximal to olecranon and just lateral to triceps. Center of anconeus triangle.
Structures at risk are posterior antebrachial cutaneous nerve, ulnar nerve, and medial brachail cutaneous nerve.
11
Q
Contraindication to elbow arthroscopy?
A
Prior ulnar nevrve transposition.
12
Q
What portal should generally be avoided in elbow arthroscopy?
A
Posteromedial.
13
Q
Which total elbow design has the best results?
A
semi-constrained or “linked”. Sloppy hinge to reduce stress on the bone cement interface. Conrad-Moorey design is an example of this.
14
Q
How long should you immbolizie a limb after TEA?
A
4 weeks. Early mobilization is associated with wound complications and early component loosening.
15
Q
What is the most common mode of failure for a semi-constrained elbow?
Constrained?
A
Instability.
Aseptic loosening.
16
Q
Apporaches for TEA?
A
Tri-ceps splitting, tri-ceps reflection, or tri-ceps sparing (difficult but ok for very distal humerus fractures)
17
Q
Relative contraindication to unconstrained TEA?
A
Lates stage rheumatoid arthritis. Distended capsule, bone erosions, and ligamentous compromise make this option likely to be unstable.
18
Q
15 yr survival of TEA in rheumatoid patients?
A
90%
19
Q
Risk factors for little leaguers elbow?
A
Greater than recommended pitch count for age:
50 pitches for 8-10 year olds. Goes up by 10-15 pitches every 2 years.
More than 8 months of pitching per year.
Fastball speed > 85 mph.
More than 2 games per week.
Pitching when having pain or fatigued.
Participating in showcases
20
Q
What elbow motion is necessary for a patient to perform ADLs?
A
Need 100 degree arc of motion.
Up to 30 degree loss of extension is well tolerated in most patients.
50-50 prono-supination.
Flexion loss casues more dysfunction than extension loss.
21
Q
Which ligament contracture is involved in elbow stiffness?
A
Posterior oblique portion of the medial ulnar collateral ligament.
Seen when flexion is less than 90-100 degrees.
22
Q
Primary ligaments of the elbow?
A
Medial ulnar collateral ligament.
Radial collateral ligament.
Annular ligament.
23
Q
Two categories for pathoanatomy of elbow stiffness and contracture?
A
Intrinsic causes: within the joint such as loose bodies, intra-articular fractures, arthritis, and joint incongruity.
Extrinsic causes: without the joint such as eschar, HO, capsular contraction and ligament conracture.
24
Q
First line of treatment for elbow contractures?
How long?
A
Supervised exercise therapy with static elbow splinting over a 6 month period.
25
Injury to what elbow structure lead to a positive pivot shift of the elbow.?
Lateral ulnar collateral ligament. Insufficiency of this ligament leads to posterolateral rotatory instability.
26
Most common type of elbow arthritis?
Rheumatoid arthritis.
20-50% of rheumatoid patients have elbow involvement.
27
Primary stabilizers of the elbow.
Anterior band of MCL. Anterior oblique fibers are most important.
LCL
Articular congruity between trochlea, coronoid, and olecranon.
28
Contraindication to TEA?
Prior ulnar nerve transposition.
Charcot joint.
Age \<65 in active patients.
29
Individuals most likely to have primary OA of the elbow?
Middle Aged laborers.
Men 4:1
30
Option for young and active patient with end stage elbow arthritis?
Ulnar humeral distraction interposition arthroplasty
Outerbridge-Kashiwagie Procedure (olecranon fossa debridement).
31
What procedure is best for relieving pain in a young patient with symptomatic elbow arthrits that has failed non-operative treatment?
What procedure is best for improving elbow ROM in a young patient with symptomatic elbow arthritis that has failed non-operative treatment?
Arthroscopic debridement
Open debridement
32
Who usually gets osteochondritis dessicans of the elbow?
Children over 10.
Boys \> Girls
Gymnasts and throwing athletes
33
Where is osteochondritis dessicans of the elbow most commonly found?
Capitellum
34
What is Panner's Disease?
Osteochondrosis of the capitellum in children \< 10 years old.
Involves the entire ossific nucleus of the capitellum not just an area.
Surgery not recommended. Benign and self-limiting.
35
Presentation of OCD of the elbow?
Insidious activity related onset.
Lateral elbow pain.
Early mild loss of extension.
Small effussion.
Catching, crepitus, and locking is a late finding.
36
Three types of OCD lesions in elbow.
Type I: Intact cartilage, bony stability may or may not be present.
Type 2: cartilage fracture, with bony collapse or displacement.
Type 3: Loose bodies in joint
37
Non-operative treatment of OCD lesion of the elbow.
Cessation of activities for 3-6 weeks. +/- immobilization.
Gradual return to activities over 6-12 weeks.
This is for stable type I lesions
38
Return to activity after microfracture or cartilage fixation of elbow OCD?
Early protected ROM
Strengthening at 2 months
No throwing or weight bearing until 4-6 months.
39
Another potential cause for lateral elbow pain in a child other than OCD that does not typically cause an effussion?
Plica
40
Eccentric overload at the origin of which tendon causes lateral epicondylitis?
ECRB
May also involve ECRL and ECU
41
What does microscopic evaluation of tissue involved in lateral epicondylitis show?
Angiofibroblastic hyperplasia
disorganzied collagen
42
What condition can be associated 5% of the time with lateral epicondyltis?
radial tunnel syndrome
PIN enters the supinator just distal to the radial head.
43
What tendons are involved in the common extensor wad?
ECRB, ECRL, ED, ECU, and Aconeus.
Anconeus shares the same attachment site as ECRB at the lateral epicondyle.
44
Success rate of non-operative treatment of lateral epicondylitis?
How long before considering operative treatment?
95%
At least 6 months.
45
Where is the ECRB located in relation to the ECRL
Whend debriding ECRB what is the risk of extending beyone the equator of the radial head?
Deep and Posterior
LUCL injury.
46
What is the treatment of choice for lateral epicondylitis?
Physical therapy.
Should perfrom Eccentric exercises.
47
What muscles are included in the flexor pronator mass?
What is their innervation?
Pronator teres ( median)
FCR (median)
FDS (median)
Palmaris Longus (median)
FCU (ulnar)
48
What is a commonly associated condition of medial epicondylitis?
What condition needs to be ruled out?
Ulnar neuritis
UCL injury or incompetency
49
What are complications of corticosteroid injections in peritendinous tissues
Skin depigmentation
Subcutaneous atrophy
Tendon weakening
Ulnar nerve injury
50
What is valgus extension overload?
Posteriormedial elbow pain common in throwing athletes.
Can lead to MCL becoming attenuated, loose bodies, capitellum
51
What condition is most associated with Pitchers Elbow?
Cubital tunnel syndrome 25% of the time.
52
When does pain typically occure with pitchers elbow?
Deceleration phase.
Will find loss of terminal elbow extension.
53
What is the most common finding on plain films for a patient with valgus extension overload?
Osteophyte formation in the posteromedial olecranon fossa.
54
What is the operative treatment for valgus extension overload?
What is a potential complication?
Resection of posteromedial osteophytes, removal of loose bodies, and debridement of chondromalacia?
Resection of olecranon leading to loss of bony restraint, increased tension in the MCL and possible valgus instability .Care should be taken to only resect osteophytes and not normal olecranon.
55
How do you test for valgus instability of the elbow?
Milking Maneuver.
Bend elbow to 90 degrees and pull the thumb laterally.
56
How do you perform a lateral pivot-shift test of the elbow?
Patient supine with affected arm overhead.
Supinate forearm and apply valgus stress to the elbow while bringing it from full extension to 40 degrees of flexion.
57
What are the bundles of the MCL of th elbow?
What are their stability roles?
Anterior and posterior bundles. (Also known as anterior and posterior oblique ligament). Anterior bundle is subdivided into anterior and posterior bands.
Anterior band is the primary restraint to valgus stress at 30-120 degrees. isometric during elbow ROM.
The posterior band is the primary restraint at 120 or more degrees.
Transverse ligament is the third portion and has no contribution to stability.
58
Where does a partial distal biceps avulsion occur?
Radial side of the tuberosity footprint.
59
What are the two distinct origins, insertions, and primary fuctions of the bicep?
Short Head: O- coracoid process I- distally on radial tuberosity, better flexor.
Long Head: O-superior glenoid and glenoid labrum I-Proximally on radial tuberosity (oval footprint), better supinator.
60
How much strength is lost with a distal biceps avulsion?
50% supination sustainted
40% supination
30% flexion
15% grip strength
61
When considering surgical repair for a distal biceps rupture:
Can you hyperflex to acheive fixation?
Do subacute and chronic repairs require direct repair or allograft augementation?
Ok to hyperflex. No loss of motion, nor does it lead to flexion contracture.
Still can perfrom direct repair without allograft.
62
What nerve injury is most common in distal biceps reconstruction?
Lateral antebrachial cuntaneous nerve.
Caused by too much retraction.
Typically resolves in 3-6 months.
More common with the single incision technique
63
What internal is used for a single anterior incision distal biceps repair technique?
If using a two incision technique what posterior interval is used?
Brachioradialis and pronator teres
ECU and EDU. Do not use interval between ECU/Anconeus and Anconeus and Ulna. Exposing the ulna can lead to HO.
64
How to you avoid PIN injury in distal biceps repair?
Avoid forceful lateral retracion.
Maintain supination, especially when drilling beath pin.
65
In wich phases of throwing is the most valgus stress placed on the elbow?
1. Acceleration phase (early)
2. late cocking
66
How do elbow MCL injuries typically present if they aren't traumatic.
loss of velocity and accuracy.
Medial or posterior pain with late cocking and early acceleration.
Should be distinguished from posteromedial pain that is felt during deceleration phase that is seen with valgus extension overload.
67
Differentiate VPMRI and VPLRI of the elbow?
68
What is the first line of treatment for MCL injury in throwers.
6 weeks of no activity withthrowing for flexor-pronator strengthening.
69
Which method of anterior band MCL reconstruction is best?
Humeral docking is stronger, has higher rate of return to sports, and lower complication rates.
Still only 95% strenght of native ligament.
Autograft favored. palmaris longus, gracilis if they don't have one.
Early motion. Strengthening at 6 weeks. No valgus stess until 4 months. Takes 9-12 months to return to throwing.
70
What is the biomechanical mechanism that leads to LCL injury and PLRI of th elbow?
forearm supination, axial loading, valgus(posterolateral stress), and elbow extension.
This leads to progressive failure of lateral collateral ligament complex and the anterior capsule.
71
What makes up the LCL Complex?
1. Accessory lateral collateral ligament.
2. Annular ligament.
3. Lateral radial collateral ligament.
4. Lateral ulnar collateral ligament. Primary stabilizer to varus and ER stress. O-lateral epicondyle I-tubercle of supinator crest of ulna.
72
Causes other than traumatic for PLRI of the elbow?
Iatrogenic injury: Any procedures that go posterior to the equator of the radial head.
Chronic attenuation: seen from cubitus varus malunion.
73
Non-operative treatment for acute elbow dislocations?
Immobilize for 5-7 days.
Depending on stability may use extension block. Progress by 30 degrees of extension weekly with forearm in full pronation.
74
Graft Configuration for LUCL Complex Reconstruction.
tunnel through supinator crest and Y tunnel thorugh humerus.
Graft needs to cover more than 25% of the radial head to create a sling.
Graft secured with arm in neutral rotation and 45 degrees of flexion.
Can tie sutures over bone or use interference screws.
75
What happens to the center of rotation in a reverse shoulder arthroplasty?
It is moved inferior and medialized.
This allows the deltoid muscle to act on a longer fulcrum.
76
What is a absolute contraindication to reverse shoulder arthroplasty?
Axillary nerve palsy or deltoid deficiency.
77
Where should the baseplate be positioned in a reverse shoulder arthroplasy?
Inferiorly with inferior tilt.
Shown to decrease implant loosening and scapular notching.
78
What intraoperative event increases the risk of post-op dislocation in reverse shoulder arthroplasty?
Failing to repair the subscaularis.
79
What is the most common cause of revision surgery in reverse shoulder arthroplasty?
Prosthetic loosening.
80
What is the position for shoulder arthrodesis?
30-30-30
30 Abduction
30 forward flexion
30 internal rotation
81
Indications for shoulder arthrodesis?
stabilization of paralytic disorders.
brachial plexus palsy.
salvage of failed shoulder arthroplasty.
Recurrent shoulder instability.
Painful ankyloses after chronic infection.
Irreparable deltoid and rotator cuff deficiency with arthropathy.
82
Contrainidications to shoulder arthroplasty?
ipsilateral elbow or contralateral shoulder arthrodesis.
Lack of functional scapulothoracic motion.
trapezius, levator scapulae, or serratus anterior paralysis.
Charcot arthropathy during acute stages.
Progressive neurologic disease.
Elderly patients.
83
When do you consider doing a hemiarthroplasty over a reverse total shoulder?
If the patient can acheive forward flexion \> 90 degrees and the rotator cuff is deficient.
84
indications for hemiarthroplasty?
Osteonecrosis of humeral head only.
proximal humerus fracture.
Primary arthritis if glenoid bone stock is inadequate or risk of glenoid loosening is high (young active laborers).
85
Contraindication specific to hemiarthroplasty?
Coracoacromial ligament deficiency.
This is a barier to proximal migration in cases where the rotator cuff is deficient.
Superior escape will occur if both coracoacromial ligament and rotator cuff are deficient.
86
What is ideal retroversion in hemiarthroplasty and total shoulder arthroplasty?
30 degrees.
87
What happens if the tuberosity is not properly reduced in shoulder arthroplasty?
What movement will be compromised if the lesser tuberosity is placed to laterally?
deficit in rotation.
Subscapularis will be on more tension, this will lead to less external rotation.
88
What kind of organism is prpionibacterium acnes?
How long can it take for cultures to become positive?
anaerobic organism.
7-21 days.
89
What is Wright's Test?
Test for thoracic outlet syndrome.
Palpate radial pulse.
Patient rotates neck away from side being tested.
Examiner rotates and maximally abducts the shoulder. Holding the arm above the level of the head for 1 minute.
Positive test is reduction in amplitude or loss of radial pulse. Reproduction of pain or paresthesias.
90
What is the hornblower's test?
Abducting shoulder to 90 and external rotation 90 degrees.
If the shoulder falls into internal rotation it may represent teres minor pathology.
91
What nerve is most at risk with a Latarjet procedure?
Musculocutaneous nerve.
The Axillary nerve can also be injured especially during graft fixation but its less common.
92
Most common location of ulnar nerve compression?
Between the two heads of the FCU.
93
What provides the majority of stability to the elbow from 0-25 degrees?
Olecranon (bony restraint)
94
What injuries do the Snyder and Maffet classifications describe?
SLAP tears.
95
Which rotator cuff tendon is most commonly torn in older patients with anterior shoulder dislocations?
Supraspinatus.
Subscapularis tears are more common in posterior dislocations.
96
What is associated with inferior scapular notching?
Superior placement of the glenosphere.
Inadequate inferior tilt.
Superior glenoid errosion presdisposes to both of the above.
Superolateral approach.
97
What classifies glenohumeral internal rotation deficit (GIRD)
Decrease in internal rotation of 25 degrees or more of the affected shoulder compared to the contralateral side.
98
What injury will you see axillary webbing with?
Pectoralis major rupture.
99
What is a common physical exam fidning in patients with multidirectional instability?
Increaed external rotation in adduction.
100
What is SICK scapula syndrome?
Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition with dysKinesis of scapular movement.
The pectoralis minor tendon can contract secondary to scapular malpositioning leading to significant tendonitis and pain.
101
What portion of the labrum is most susceptible to vascular insufficiency?
Anterior superior portion.
102
An inverted pear shaped glenoid is indicative of what?
Severe Glenoid bone loss.
Greatly increases the risk of instability even after labral repair.
103
What is the orientation of the humeral head relative to the transepicondylar axis of the distal humerus?
What is the neck shaft angle?
Retroverted 30 degrees
130-140 degrees
104
Where should the greater tuberosity be postioned relative to the humeral canal axis?
Upper edge of the humeral head?
medial edge of greater tuberosity should be 10mm lateral to humeral canal.
Superior edge of tuberosity is 6mm inferior to upper edge of humeral head.
105
What is the importance of a MRI prior to surgery for a proximal humerus fracture malunion?
Status of rotator cuff and labrum
Look for any delotid atropy secondary to axillary nerve injury
Long head biceps injury
Any osteonecrosis
106
What are some surgical techniues for minor proximal humerus head deformities when an osteotomy is not indicated?
Arthroscopic tuberoplasty
acromioplasty
capsular release
bursectomy
107
What amount of greater tuberosity displacement/malunion in a proximal huemrus malunion warrants an osteotomy?
\> 1.5cm should do osteotomy with subacromial decompression.
108
What degree of greater tuberosity displacement will lead to altered rotator cuff biomechanics?
\>5 mm
109
What is the most common complications following posterior labral repair?
Stiffness due to immobilization and scar tissue formation.
2nd most common complications is recurrent posterior instability.
110
What is considered normal vertebral height acheived on internal rotation of the shoulder?
T4-T8
111
What is a t Sign test?
Used to test for impingement of rotator cuff tendon/bursa against the coracoacromial arch. However, stiffness, OA, instability, and bone lesions can also produce a positive test.
TECHNIQUE: Use one hand to prevent motion of the scapula. Raise the arm of the patient. Pain is elicited as greater tuberosity impines agianst the acromion (often between 70-11 degrees). Patients must have full range of motion for a postive finding.
**Neer Impingement Test-** Perform the same test above following a subacromial lidocaine injection. Considered positive if there is redcuiton in pain.
112
How do you perform a Hawkin's Test and what is it used for?
Positive with impingement.
Peformed by flexing shoulder to 90 degrees, flex elbow to 90 degrees, and forcibly internally rotate driving the greater tuberosity farther under the CA ligament.
113
How do you perform a Jobe's Test and what can it test for?
Abduct arm to 90 degrees, angle forward 30 degrees (bringing it into the scapular plane), and internally rotate (thumb pointing to floor).
Then press down on arm while patient attempts to maintain position. Positive test is weakness and pain.
**Tests for supraspinatus weakness and IMPINGEMENT.**
114
How do you perform an internal impingement test?
115
Regarding testing of subscapularis:
Which test is most sensitive and specific?
Which test is more accurate for inferior portion of subscapularis?
Which test is more accurate for superior portion of subscapularis?
Internal Rotation Lag Sign- Where patients hand is brought begind their back and lifted 20 degrees from the lumbar spine and then asked to hold it there.
Lift off test
Belly Press test
116
How do you perform a bear hug test?
Patient places ipsilateral palm on opposite deltoid and tries to resist the examiner pulling it away anteriorly.
Positive if at least 20% weaker than contralateral side.
Tests subscapularis.
117
How do you test the infraspinatus?
Strength is tested by testing external rotation strength while the arm is in at the side and neutral internal and external rotation.
**External rotation lag sign-** passively flex the elbow to 90 degrees. Holding wrist to rotate the shoulder to maximla external rotation. Tell the patient to hold the arm in that externally rotated position. If the arm starts to drift into internal rotation it is positive.
118
How do you test the teres minor?
Test external rotation strength with the arm held in 90 degrees of abduction.
**Hornblower's sign-** Bring the shoulder to 90 dgrees of abduction, 90 degrees of external rotation and ask the patient to hold this position.
Positive if the arm falls into internal rotation. It may represent teres minor pathology.
119
What is a crank test?
Tests for labral injuries or SLAP lesions.
Hold the patient;s arm in an abducted position and apply passive rotation and axial rotation.
Positive when there is clicking or pain in the glenohumeral joint. .
120
What is an O'Brien's Test?
What does it test for?
Also known as an active compression test.
Tests for labral injuries and slap lesions. Also test for AC joint pathology.
Positive when ther is pain over the AC joint when pronated or deep in the glenohumeral joint, but no when the forearm is supinated.
Pateint forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted 10-15 degrees across the body. The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patients resists. Then down with the patient supinating the forearm.
121
How do you test for anterior shoulder instability?
122
How do you test for posterior shoulder instability?
123
What is a sulcus sign?
How is it graded?
Used to diagnose multidirectional instability (MDI)
Have the patient stand relaxed with their arms at their side. Grab the affected arm and pull it inferiorly. If there is a sulcus that forms at the superior aspect of the humerla heat, the test is positive.
Sulcus is considered positive if it stays increased (2+ or 3+) with ER at side (pathologic rotator interval.
SULCUS GRADING: 1+ acromiohumeral interval \<1cm
2+ acromiohumeral interval 1-2cm
3+ acromiohumeral interval \> 2cm
124
What provides horizontal stability to the AC joint?
What provides vertical stability?
**horizontal-** acromioclavicular ligament. Superior, inferior, anterior, and posterior components. Superior ligament is strongest, followed by posterior.
**vertical-** Coracoclavicular ligament. Conoid (inserts 4.5 cm from end of clavicle) and Trapezoid (inserts 3cm from end of clavicle).
Conoid is the more important of the two.
125
What is a normal coracoclavicular distance?
superior coracoid to inferior clavicle is 11-13mm
126
When fully abducting your shoulder what two joints allow that motion and how much does each contribute?
2:1 ratio of glenohumeral joint and scapulothoracic joint.
120 degrees from the former and 60 degrees from the latter.
127
What are the three attachements to the coracoid?
coracobrachialis, pectoralis minor, and short head of the biceps attach to the coracoid.
128
What is the normal version of the humeral head and the glenoid?
HUMERAL HEAD- approximate retroversion of 20 degrees from the transepicondylar axis of the distal humerus.
Articular surface inclined upward 130 degrees from the shaft.
GLENOID- pear shaped surface with average upward tilt of 5 degrees
Average 5 degrees of retroversion in relation to the axis of the scapular body. **However, it varies from 7 degrees of retroversion to 10 degrees of anteversion.**
129
What structures pass through the rotator interval?
Long head of the biceps tendon, coracohumeral and superior glenohumeral ligament.s
130
What are the boundaries of the rotator internval?
Medially by lateral coracoid base
Superiorly by anterior edge of supraspinatus
Inferiorly by superior border of subscapularis
Lateral apex formed by transverse humeral ligament
131
Describe the glenohumeral ligaments and their restraints in different arm positions.
132
What does the anterior labrum anchor within the shoulder?
anchors IGHL
This is the weak link that leads to bankart lesions
133
What are the various anatomic variatns of the glenoid labrum?
Normal Variant 86%
Sublabral foramen 12%
Sublabral foramen + cordlike MGHL
Buford Complex (absent anterosuperios labrum + cordlike MGHL 1.5%. Cordlike middle glenohumeral ligament with attachement ot base of biceps anchor and complete absence of the anterosuperior labrum.
**Attaching a Buford complex will lead to painful and restricted external rotation and elevation?**
134
What is the most common cause for shoulder pain?
Subacromial impingement.
44-65% of shoulder disorders.
135
What is a painful arc test?
Yocum test?
Tests for subacromial impingement.
**Painful arc test-**pain with arm abducted in scapular plane from 60 to 120 degrees.
**Internal impingement test-** positive if pain is elicited with abduction and external rotation of the shoulder.
136
What is a normal distance for a acromiohumeral internal?
7-14mm
Can be evaluated on a true AP (Grashey) of the shoulder
137
What radiographs are useful for evaluating subacromial impingement and defining acromial morphology?
**30 degree caudal tilt view**- useful in identifying subacromial spurring
**Supraspinatus outlet view-** useful in defining acromial morphology
**Axillary view-** Best for seeing os acromiale.
138
What are common findings on radiographs in subacromial impingement?
Proximal migration of the humerus
Traction osteophytes
Calcification of the coracoacromial ligament
Cystic changes within the greater tuberosity
Type III-hooked acromion
Os acromiale- seen well on scapular Y. See image.
139
What will histology show in subacromial impingement.
Bursa will show inflammation- high levels of metalloproteases and other inflammatory cytokines.
Tendinopathy- will show disorganized collagen fibers, mucoid degeneration, and inflammatory cells.
140
When do you consider operative interveion for subacromial impingement?
After 4-6 months of nonoperative treatment (PT, NSAIDs, and subacromial injections).
Poor outcomes in acromioplasty patients with workers compensation claims, anxiety, and depression.
141
What are the two steps of a acromioplasty?
ONE: **anterior acromionectomy-** the anterior deltoid origin determines the extent of the acromionectomy when performed arthroscopically and must remain intact.
TWO: **anteroinferior acromioplasty-** smooth the undersurface of the acromion. A two stage procedure may be indicated for os acromiale which must be fused and allowed to heal before performing the acromioplasty.
**deltoid dysfucntion** can occur if the deltoid is not properly repaired or as a result of direct excision of an os acromiale.
142
Who most commonly gets calcific tendonitis?
What tendon is most often involved?
What are risk factors?
30-60 year old women
Supraspinatus
Diabetes and Hypothyroidism.
143
What kind of crystals are deposited in calcific tendonitis?
What key molecular pathways are involved?
What stage/phase is thought to be most painful?
calcium hydroxyapatite crystals
Osteopontin, cathepsin K, and transglutaminase 2
Three stages are precalcific, clacific, and postcalcific
Calcific is devided into three phases. Formative, resting, and resorptive. **The resorptive phase is the most painful.**
144
What is a another name for scapular Y radiograph?
supraspinatus outlet view.
145
How will patients with calcific tendonitis present?
Atraumatic pain with possible catching, crepitus, or mechanical block.
Can have supraspinatus muscle atrophy.
On physical exam: decreased active range of motion, scapular dyskinesia, and may be associated with a decrease in rotator cuff strength.
Subacromial impingement tests often positive.
146
What is the outcome of nonoperative treatment (NSAIDs, PT, and steroid injections) for calcific tendonitis?
What are other treatment options?
Resolution of symptoms in 60-70% of patients after 6 months.
**Increased probability of failure when**: bilateral or large calcification.
Deposits underlying the anterior third of acromion
Deposits extending medial to the acromion
Extracorporeal shock-wave therapy. High energy better. Used for refractory tendonitis in the formative and resting phases.
Ultrasound-guided needle lavage vs needle barbotage. Used in the resorptive phase.
147
What are the three ossification centers of the acromion?
Meta-acromion (base): origin of posterior portion of deltoid
Meso-acromion (mid): Origin of middle deltoid
Pre-acromion (tip): Origin of anterior deltoid fibers and coracoacromial ligament
Blood supply is acromiale branch of thoracoacromial artery.
148
What treatment is recomended for os acromiale?
149
What is the prevalence of full thickness cuff tears in those
age \> 60 years
age \>70 years
What are risk factors?
age \> 60 years 28% have full-thickness tear
age \> 70 years 65% have full-thickness tear
RISK FACTORS: Age, smoking, hypercholesterolemia, and family history.
150
At what phase of the throwing cycle are athletes at risk for rotator cuff tears?
Deceleration phase.
Must susceptible to tensile failure due to eccentric loading during this phase.
partial thickness rotator cuff tears seen from internal impingement.
151
What is the general prognosis of asymptomatic rotator cuff tears?
What is the general prognosis of symptomatic full-thickness tears ?
50% of asymptomatic tears become symptomatic in 2-3 years
50% of symptomatic full-thickness tears progress at 2 years and bigger tears progress faster.
152
Describe the footprint of the rotator cuff?
Medial to lateral dimensions?
Anterior to posterior dimensions?
Supra inserts on anterosuperior aspect of greater tuberosity.
**Medial-lateral width at insertion**: supra is 12.7mm (6-7mm tear corresponds to 50% partial thickness tear)
Infra is 13.4mm, subscap is 17.9mm, and teres minor is 13.9mm
**AP Dimension:** 20mm supra to anterior aspect of infra.
Distance between articular cartilage to medial foot print of cuff is 1.6-1.9mm
153
True or False: Articular side of the rotator cuff only has hald the strength of the bursal side?
True
This is why most tears are on the articular side.
154
What is the blood supply to the rotator cuff?
From subscapular, suprascapular, and humeral circumflex arteries
Bursal side is more vascular than the articular side, which is hypovascular.
Zone of critical hypovascularity adjacent ot most lateral portion of supraspinatus insertion.
155
What is the rotator cable and crescent?
**Rotator crescent:** is a thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus insertions. The cresecent is bounded at its proximal margin by a thick bundle of fibers called the **rotator cable**.
156
What is the tangent sign with regards to rotator cuff pathology?
Failure of the supraspinatus to cross a line drawn between the superior borders of the scapular spine and coracoid process on a sagittal MRI slice.
157
What is a PASTA lesion?
Articular sided rotator cuff tear where tendon is avulsed from the bone.
\>7mm of exposed bony footprint wetween articular surface and intact tendon represents significant (\>50%) cuff tear.
158
What is an indication for subacromial decompression and rotator cuff debridement alone?
Only in select patients
Low-grade partial articular sided roator cuff tears.
159
True or false failure to heal the rotator cuff tendon to bone consistently results in poor patient outcomes?
False
Hearly half of all rotator cuff repairs do not successfully heal tendon back to bone. However, this has not been shown to decrease patient outcomes.
160
What are surgical indications for rotator cuff tears?
Acute full-thickness tears.
Bursal-sided tears \> 3mm (\>25%) in depth. Release reamining tendon and debride degenerative tissue.
Partial articular sided tears \>50%. Those less than 50% can be treated with debridement alone.
PASTA: younger patients with acute, traumatic tears -\> in situ repair while leaving bursal sided tissue intact. Older patients with degenerative tears -\> tendon release, debridement of degenerative tissue and repair.
161
What two tendons attatch to the superolateral margin of the subscapularis tendon?
Coracohumeral and superior glenohumeral ligaments
Marked by the asterisk in the image.
Useful because the subscap becomes scarred to deltoid fascia making it hard to identify.
The coracohumeral and superior glenohumeral ligaments form a complex otherwise known as a comma sign that can be used to identify the scarred and rectracted subscap tendon.
162
True or false new studies show improved results (with regard to motion and pain) with arthroscopic repair of subscap tendons.
True
Although it is technically more challenging.
163
What creates a more anatomic repair and footpring when repairing rotator cuff repairs, single or double row repairs?
Which has a lower retear rate?
What is the difference in funcitional score, pain score, and time to healing between the two?
Double row repair creates a more anatomic repair of the footpring.
Double row has lower retear rate.
No difference found between the two for time to healing, pain scores, and functional scores.
164
When is a pectoralis major transfer indicated?
Chronic subscapularis tears.
Transferring pectoralis major under the conjoined tendon more closely replicates the vector forces of the native subscapularis.
Requires 4-6 weeks of rigid immobilization.
165
When is a latissimus dorsi transfer indicated?
Large supraspinatus and infraspinatus tears
Best candidate is a young laborer
Attach to cuff muscles, subscap, and GT
Brace immobilize for 6 wks in 45 abduction and 30 degrees ER.
166
What two nerves are at risk with a latissimus dorsi transfer?
**Radial nerve-** runs along anterior surface of latissimus dorsi, 3cm medial to humeral insertion, at risk during tenotomy.
**Posterior branch of the axillary nerve-** runs in deep fascia of posterior deltoid. At risk during passage of tendon deep to deltoid to subacromial space.
167
What is the most common cause of RCR failure?
Failure of cuff tissue to heal resulting in **suture pull out from repaired tissue.**
168
What are risk factors for RCR failure?
Age \> 65
Large tear size \> 5cm
Muscle atrophy
Diabetes
Smokers
Tear retraction medial to glenoid
Poor compliance with postop-protocol. No difference found in early vs delayed motion protocols.
Multiple tendons involved.
Concomitant AC and/or biceps procedures performed at time of repair.
169
When can you see a suprascapular nerve injury after RCR?
May occur with aggressive mobilization of supraspinatus during repair.
170
Does early physical therapy and guided early range of motion exercises reduce stiffness post-op after rotator cuff repairs?
No
171
What is another cause of biceps subluxation other than subscap tears?
Disruption of the biceps sling.
Comprised of: fibers of the subscapularis, supraspinatus, coracohumeral ligament, and superior glenohumeral ligaments.
172
What are the two provocative biceps tests:
**Speeds test-** Resisted shoulder flexion with the shoulder flexed to 90 degrees, elbow flexed to 90 degrees. Anterior shoulder pain is positive.
**Yergasons-** Arm at side and elbow flexed to 90 degrees have the patient supinate the arm against resistance. Anterior shoulder pain is positive.
173
What are the demographics, location, and risk factors for rotator cuff tear arthropathy?
DEMOGRAPHICS: females \> males. 7th decade most common.
LOCATION: more common in dominant shoulder
RISK FACTORS: rotator cuff tear. Rheumatoid arthritis. Crystalline-induced arthropathy. Hemorrhagic shoulder (hemophiliacs and elderly on anticoagulants).
174
Lack of osetophytes, osteopenia, and anterosuperior escape is consistent with what shoulder pathology?
Rotator cuff arthropathy.
Important that rheumatoid arthritis that has many of the same findings is a cause of rotator cuff arthropathy. However rheumatoid disease without cuff tear arthropathy will present with different wear patterns.
central in strict rheumatoid disease while there is assymetric glenoid wear in rotator cuff tear arthropathy.
175
Can you perform a reverse total shoulder arthroplasty if the shoulder exhibits anterosuperior escape?
Yes
anterosuperior escape is a contraindication to hemiarthroplasty that is sometimes performed in patients who are not a condidate for total shoulder arthroplasty but are too young and not good condidates for a reverse.
176
If a patient has internal rotation and subscapularis insufficiency of their shoulder and is going to undergo a reverse shoulder arthroplasty what procedure may also be indicated?
What nerve can be injured?
Pectoralis transfer
Musculocutaneous nerve injury.
Upper portion or whole pectoralis tendon transferred near subscapularis insertion on lesser tuberosity.
177
When is a latissimus dorsi transfer indicated in compbination with a reverse total shoulder arthroplasty?
When their is pseudoparesis with external rotation (teres minor dysfunction)
Demonstrated by a positive horn blowers test.
178
What stabilized the long head of the biceps tendon within the bicipital groove?
Transverse humeral ligament.
179
Is there any difference in elbow and forearm strength between biceps tenotomy and tenodesis?
What is a complaint with tenodesis?
What is a complaint with tenotomy?
No difference.
cosmetic deformity and arm cramping.
groove pain.
180
What motion occurs through the AC joint?
Primarily gliding motion
Rotational motion is minimal:
Clavicle rotates 40-50 degrees posteriorly with shoulder elevation.
Only 8 degrees rotation through the AC joint due to synchronus scapuloclavicular motion
181
What view is needed besieds AP and Axillary lateral to evaluate the AC joint?
Zanca View- performed by tilting the x-ray beam 10-15 degrees cephalad and using only 50% of the standard shoulder AP penetrance.
This view is not needed but useful to know about. **Basmania**- scapular Y with cross-body adduction stress to look for instability.
182
What is the Rockwood Classification of AC joint injuries?
183
What are the outcomes when comparing type III AC joint injuries treated non-op and with surgery?
Those treated non-op had higher DASH scores at 6 weeks and 3 months.
Equal function at 1 year with lower rate of secondary surgery (removal of hardware) compared to those treated operatively.
184
What is non-op rehab for AC joint separation?
Early shoulder range of motion
Regain functional motion by 6 weeks
Return to normal acitivty at 12 weeks
consider corticosteroid injections
185
What is Modified Weaver-Dunn Procedure?
Distal clavicle excision with transfer of coracoacromial ligament to the distal clavicle to recreate CC ligaments.
**Coracoacromial ligament only 20% strong as normal CC ligament.**
For this reason ligament reconstruction is more often done with a free tendon graft.
186
What percentage of patients have residual pain at the AC joint after an AC joint separation?
Is AC joint arthritis more common with surgical or non-operative manangement?
30-50%
More common with surgical management.
187
What causes distal clavicle osteolysis?
Repetitive stress and micro-fracture that leads to osteopenia.
Most patients are males in their 20s. Common in weight lifters.
Differentiated from AC joint arthritis by lack of acromial involvement on radiographs. Will see cysts, osteopenia, resorption/erosion and tapering of the distal clavicle.
188
Treatment for distal clavicle osteolysis?
First line: NSAIDs and activity modification. Avoid aggravating weight-lifting exercises or modify technique. **move hand grip closer together and end weight descent to 4 to 6 cm above the chest.**
Can try corticosteroid injections
Open or arthroscopic distal clavicle excision in refractory cases that fail non-operative management.
189
What non-operative treatment is recommended for AC joint arthritis?
Avoid aggravating activity. PT should focus on strengthening and stretching of shoulder girdle.
AC joint injection can be both diagnostic and therapeutic. AC joint injection often miss the joint. **Better success with ultrasound.** Most patients do not experience long term relief after injections.
190
What are complications from distal clavicle resection?
AC joint instability seen when more than 1 to 1.5cm are resected.
too far medial can compromise the cc ligaments leading to superior/posterior instability.
Aggressive debridement can also sacrifice posterior and superior AC ligaments leading to anterior to posterior instability.
Persisten pain due to incomplete resection. Most commonly of the posterior-superior area of the distal clavicle.
**Deltoid dehicence if there is inadequate deltotrapezial fascia repair after open distal clavicle resection.**
191
What are common associated injuries with Luxatio Erecta?
**neurovascular injury- has greatest incidence of this of all shoulder dislocations.** Neurologic injury in 60%.
Vascular injury up to 39%
Proximal humerus fractures
Rotator cuff tears
Anterior capsule and labral tears
Commonly involves variable sized tearing of static glenohumeral ligaments
192
What should be performed after reduction of luxatio Erecta?
Neurovascular exam given high rate of injuries.
Most common nerve palsy is **Axillary nerve palsy.** If persists 6-12 weeks past injury -\> EMG
Axillary artery thrombusis that **may occur late**
MRI- because high likelihood of soft tissue injuries
193
What does TUBS stand for?
**T**raumatic **U**nilateral dislocations with a **B**ankart lesion requiring **S**urgery
One of the most common shoulder injuries
Occur in younger patients.
90% chance for recurrence in age\< 20 years.
194
What mechanism leads to a TUBS injury?
Anterior shoulder dislocation.
Anteriorly directed force on the arm when the shoulder is abducted and externally rotated.
195
What labral and cartilage injuries are associated with traumatic anterior shoulder dislocations?
LABRAL & CARTILAGE INJURIES: **Bankart lesion-** avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferiro glenoid. Present in 80-90% of patients with TUBS
**HAGL****-** humeral avulsion of the glenohumeral ligament. Occurs in patients who are slightly older. Higher recurrence rate if not recognized and repaired. Indication for possible open surgical repair.
**GLAD-** Glenoid labral articular defect. Sheared off portion of articular cartilage along with labrum.
**ALPSA-** Anterior labral periosteal sleeve avulsion. Can cause torn labrum to heal medially along the medial glenoid neck. Associated with higher failure rates following arthroscopic repair.
196
What injury does this image dipict?
HAGL- Humeral avulsion of the glenohumeral ligament.
197
What fractures and bone defects are associated with traumatic anterior shoulder dislocations?
**Bony Bankart lesion-** Fracture of anterior inferior glenoid. Present in up to 49% of patients with recurrent dislocations. Defect \>20-25% is considered "critical bone loss? and is highly unstable. Require bondy procedure to restore bone loss.
**Hill Sachs defect-** chondral impaction injury in the posterosuperior humeral head. Present in 80% of traumatic dislocations and 25% of traumatic subluxations. It is not clinically significant unless it engages the glenoid.
**Greater tuberosity fracture-** Higher association in those \> 50 years of age
**Lesser tuberosity fracture-** Is associated with posterior dislocations.
198
What is the incidence of rotator cuff tears in traumatic shoulder dislocations for patients \> 40 years of age?
\> 60 years?
30%
80%
199
What provides the main restraint within the shoulder for anterior static shoulder stability?
Anterior band of IGHL (main restraint)
Provides static restraint with arm in 90 degrees of abduction and external rotation.
200
Describe the instability severity score for the shoulder?
201
What are some useful shoulder radiographs for visualizing bone loss or defects in someone who has had a shoulder dislocation that is now relocated?
**West point view-** shows glenoid bone loss.
**Stryker view-** shows Hill-Sachs lesion.
202
What are the physical exam findings found or helpfult signs in a patinet with shoulder instability?
203
What patients are at higher risk of re-dislocation of their shoulder and would be controversial for nonoperative treatment?
Age \<20 years
Male
Contact Sports
Hyperlaxity
Glenoid bone loss \> 20-25%
204
What immobilization is recommended after a traumatic shoulder dislocation has been reduced in a patient that will be treated non-operatively?
Studies have not shown any benefit of immobilization \> 1 week for decreasing recurrence rates.
Some studies show immobilization in external rotation decreases recurrence rates in patients \< 40. Thought to reduce the anterior labrum to the glenoid leading to more anatomic healing. **However subsequent studies have refuted this finding.**
205
What are the indications for arthroscopic bankart repair?
First time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age.
High demand athletes
Recurrent dislocation/subluxation (\>one dislocation) following nonoperative management.
\<20% glenoid bone loss
Remplissage augmentation with arthroscopic Bankart may be considered if Hill-Sachs is "off track"
206
What are the indications for an open Bankart repair?
Bankart lesion with glenoid bone loss \< 20-25%
Revision stabilization following failed arthroscopic Bankart repair without glenoid bone loss \> 20%
HAGL- Humeral avulsion of the glenohumeral ligament. Can be performed arthroscopically but is very challenging and most arthroscopic surgeons prefer to perform this open.
207
When is a Latarjet indicated?
Chronic bone deficiencies wtih \>20-25% glenoid deficiency. (more indicated in those with inverted pear deformity of glenoid)
Transfer of coracoid bone with attached conjoined tendon and CA ligament.
**Latarjet triple effect =** bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule reconstruction (CA ligament)
208
When is Remplissage indicated?
When is bone graft reconstruction indicated instead?
Engaging large 25-40% Hill-Sachs defect.
Off track Hill-Sachs lesions with \<20-25% glenoid bone loss
Posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion.
Engaging large \>40% Hill-Sachs lesions
209
What are Putti-Platt/ Magnuson-Stack/ Boyd-Sisk procedures?
All are some variation of tightening subscapularis with advancement or plication.
Of historical signifigance only.
Led to over-constraint and arthrosis.
Typical presentation is someone had a procedure in the 1970s or 1980s and now has pain, lack of external rotation, and glenohumeral OA. Significant posterior glenoid wear and retroversion.
210
How many anchors do studies support the use of in Arthroscopic Bankart Repairs?
Studies support the use of 3 or more anchors.
Less than 3 anchors ia risk factor for failure.
211
What are complications with open capsulr shift?
Inferior capsule is shifted posteriorly thorugh a deltopectoral approach.
**subscapularis injury or failed repair-** will show a positive lift off and excessive ER
**Overtightening of capsule-** leads to loss of external rotation. Treat with Z lengthening of subscapularis
**Axillary nerve injury-** Iatrogenic injury with surgery. Avoid by abduction and ER of arm during procedure.
**Late arthritis-** usually wear of posterior glenoid, may have internal rotation contracture. Seen with Putti-Platt and Magnuson-Stack procedures.
212
What are complications associated with Latarjet procedures?
Up to 25% incidence of complications reported with this procedure. They include:
nonunion, graft lysis, hardware problems
stiffness, particulary in external rotation
Glenohumeral arthritis- will rapidly occur with lateral overhand of graft into the joint space.
**Nerve injury-** Most are traction or contusion and will resolve spontaneously. Occurs furing glenoid exposure. If not imporved in 6 weeks obtain an EMG. Musculocutaneous neve is most common (occurs during instrumentation around the conjoint tendon). Axillary nerve also at risk. Occurs during graft fixation.
213
What shoulder dislocation is most common with seizures?
Still an anterior dislocation!
Howerver posterior dislocations are seen with seizures.
Also common in lineman, weight lifters, and overhead athletes. Microtrauma leads to labral tear, avulsion, and erosion of the posterior labrum. this leads to gradual stretching of capsule and patulous posterior capsule.
Posterior dislocations are only 2-5% of all unstable shoulders.
214
What is the high risk position for a posterior shoulder dislocation?
Flexed.
Adducted.
Internally rotated.
215
What lesions are associated with posterior shoulder instability?
216
What is the primary static stabilizer to posterior subluxation with shoulder in flexion, adduction, and internal rotation?
Superior glenohumeral ligament and coracohumeral ligament.
217
What provocative tests can be performed in the setting of chronic posterior instability?
218
What is a kims lesion?
Concealed avulsion of the deep posteroinferior labrum, with apparently intact superficial labrum.
Other posterior shoulder lesions are reverse bankart and reverse hill sachs lesions.
219
What may a lightbulb sign on AP radiograph of the shoulder be indicative of.
Posterior shoulder dislocation.
220
What treatment should be attempted in all posterior shoulder dislocations?
Reduction and immobilization in external rotation for 4 to 6 weeks.
Immobilize in 10-20 degrees of external rotation with elbow at side.
After 6 weeks advance to physical therapy (rotator cuff strengthening and periscapular stabilization) and activity modification (avoid activities that place the arm in high-risk position).
**most dislocations reduce spontaneously.**
221
What is the 1st, 2nd, and 3rd most common complications after labral repair?
1st- Stiffness
2nd- Recurrence
3rd- Degenerative joint disease
222
What may overtightening of the posterior capsule in cases of posterior shoulder instability lead to?
Anterior subluxation
Coracoid impingement
223
What are the indications for open or arthroscopic posterior Bankart repair?
Outcomes?
Recurrent posterior shoulder instability despite appropriate course of physical therapy
Continued pain with loading of arm in forward flexed position (bench press, football blocking)
Negative Beighton score
OUTCOMES: 80-85% success at 5 to 7 year follow-up for open repair.
Similar outcomes for arthroscopic repair just with shorter follow-ups.
224
What would be an indication for posterior capsular shift and rotator interval closure?
Positive Beighton score.
225
What is the treatment for a posterior shoulder dislocation that is 5 months old and has a reverse Hill-Sachs defect that is 35% in size?
Open reduction with
subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin)
Modified McLaughlin is more comonly used.
Indications are generally for chronic posterior shoulder dislocation \< 6 months old and reverse Hill -Sachs defects \< 40%.
226
How would you treat a posterior shoulder dislocation that is 8 months old?
Hemiarthroplasty.
Other inidcations: severe humeral head arthritis. Collapse of humeral head during reduction. Reverse Hill-Sachs defect \> 40% of articular surface.
If there is significant glenoid arthritis in addition then total shoulder arthroplasty should be performed.
227
What is AMBRI of the shoulder?
**A**traumatic, **M**ultidirectional **B**ilateral (frequently) **R**ehabilitation (often responds to) **I**nferior capsular shift (best alternative to nonop)
Another name for Multidirectional shoulder instability (MDI)
Peaks in second and third decades of life.
228
What is the underlying mechanisms of MDI or AMBRI?
**Microtrauma from overuse-** seen with overhead throwing, volleyball players, swimmers, and gymnasts.
**Generalized ligamentous laxity-** associated with connective tissue disorders: Ehlers-Danlos and Marfan's syndrome
229
What are the hallmark findings of MDI on imaging?
Patulous inferior capsule on MRI (IGHL anterior and posterior bands)
**rotator interval deficiency**
230
What is a drive through sign on shoulder arthroscopy?
A positive drive through sign is considered to be the ability to pass an arthroscope easily between the humeral head and the glenoid at the levle of the anterior band of the IGHL.
See in patients with MDI or shoulder laxity.
231
What physical exam tests of the shoulder must be present for a diagnosis of MDI?
What other tests may be positive?
**Must have instability in 2 or more planes to be defined as MDI.**
Sulcus sign (2+ or more)- Assesses rotator interval. Laxityof rotator interval presents as increased external rotation with the arm fully adducted and at 90 degrees abduction.
Apprehension/relocation test
Anterior and posterior load and shift test (2+ or more)
Neer and Hawkins test- impingement or rotator cuff tendonitis in \<20 year old sigals possible MDI
232
What is Beighton's criteria?
9 point scoring system for hypermobility.
Score greater than 4 is associated with multidirectional instability of the shoulder.
Score greater than 6 is associated with connective tissue disorders such as Marfan's and Ehlers-Danlos Syndrome.
233
What is first line treatment for shoulder MDI?
If that fails?
3-6 months regiment of dynamic stabilization physical therapy.
Strengthening of rotator cuff and periscapular musculature
Closed chain kinetic exercises are used early in the rehabilitation process to safely stimulate co-contraction of the scapular nad rotator cuff muscles.
Capsular shift/stabilization procedure: Must address capsule and +/- on rotator interval closure as this produces the most decrease in range of motion. **Primarily restricts eternal rotation with the arm at 0 degrees of shoulder abduction.**
234
What is post-op rehab for treatment of shoulder MDI that was treated with capsular shift?
4-6 weeks: in shoulder immobilizer or sling.
6-10 weeks: ADL's with 45 degree limit on abduction and external rotation.
10-16 weeks: gradual increase ROM
\> 16 weeks: strengthening
\> 10 months: contact sports
**Patient should resume sport activities only after normal strength and motion have returned.**
235
What is the most common complication follwoing treatment of shoulder MDI?
Other compications?
Recurrent instability
High rate historically following thermal capsulorrhaphy due to capsular insufficiency.
In these cases open revision must be performed.
**subscapularis deficiency:** more common after open anterior-inferior capsular shift. May be caused by injury or failed repair. Will have positive lift off test, excessive external rotation. Late finding is humeral head anterior subluxation on axillary radiograph.
**Loss of motion-** may be due to asymmetric tightening. Loss of external rotation. Treated with Z-lengthening of subscapularis. RARE
236
What is the incidence, demographics, and risk factors of SLAP lesions
uncommon, accounts for less than 5% of all shoulder injuries.
Dominant shoulder of overhead throwing athletes.
Also seen in patients who fall on outstretched arm with tensed biceps.
Glenohumeral internal rotation deficit.
237
What is the pathoanatomy of a SLAP lesion?
In throwers may be due to tightness of the posterior-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum.
SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder
238
What is the blood supply to the labrum?
What area has the poorest blood supply?
From suprascapular, circumflex scapular, and posterior humeral circumflex arteries.
Labrum receives blood from capsule and periosteal vessels and not from underlying bone.
Anterior-superiro labrum has poorest blood supply.
239
What is the classification system for SLAP tears?
What is the most common type?
Snyder Classification: original classification which includes Types I-IV in the image.
Maffet sub-classification: Includes the original I-IV and added Types V-VII.
**Most common is Type II. Labral fraying with detached biceps tendon anchor. 41% of the time.**
240
What is the best provocative test for SLAP lesions?
**There is no one specific test. Multiple will be positive.**
Biceps provocation tests will often be positive: Speed's, Yergason's, and Kim biceps load test
SLAP LESION TESTS: active compression test (O'Brien's test)
Crank test (arm placed in full abduction and humerus loaded and rotated)
Dynamic labrla shear test. Kebler anterior slide test. Apprehension positive in 85% of patients.
241
What is a spinoglenoid notch cyst almost always associated with?
Paralabral ganglion cyst in the spinoglenoid notch is highly specific for labral tears.
242
For SLAP lesions that have failed non-operative treatment which undergo arthroscopic debridement?
Which undergo debridement with repair of the labrum and biceps.
Which undergo debridement labral repair and biceps tenotomy/tenodesis?
Types I, III, and IV involving \< 1.3rd of the cieps tendon -\> Arthroscopic debridement
Type 2 tears -\> Arthroscopic debridement with repair of the labrum/biceps. Highly controversial. **General consensus is to perfrom tenotomy for those over 40 years of age.** These are traditionally found in overhead athletes. Return to play rates after SLAP repairs are significantly lower for pitchers compared to non-pitchers.
Type I, II, and IV tears with \>1/3rd of the biceps tendon -\> Arthroscopic debridement with repair of debridement of the labrum with biceps tenotomy/tenodesis.
243
True or False: It is traditionally thought that sutures placed anterior to biceps anchor in SLAP repairs increases stiffness post-operatively?
True
244
In general what is the recommended rehab after arthroscopic debridement and stabilization of a SLAP lesion?
How long before return to sport?
Week 1-4: passive and active assited flexion in the scapular plane. **avoid extremes of abduction and external rotation, and resisted bicpes exercises.**
Week 4-6: Progress to active ROM, isometrics
Week 6-12: Functional exercise and light strengthening
Week 12+: Advance strength and ROM, sport specifics.
**typical return to sport around 6 months?**
245
What is the most common complication following SLAP repair?
Treatment?
Stiffness. Occurs in 78% of all patients.
Risk factor: Incidental SLAP lesions repaire din older patients (\>45 years) having arthroscopic rotator cuff repair.
Early passive and active assisted ROM (pendulum) exercises beginning 1 week following repair. **If stiffness does not resolve with physical therapy, capsular release is indicated.**
246
What is at risk with overdrilling of the glenoid during SLAP lesion repairs?
Suprascapular nerve injury.
247
Internal impingement covers a spectrum of injuries that include?
Fraying of posterior rotator cuff (supraspinatus-infraspinaturs interval)
Posterior and superior labral lesions
Hypertrophy and scarring of posterior capsule glenoid (**Bennett lesion)**
Cartilage damage at posterior glenoid.
248
What conditions are associated with internal impingement?
GIRD
SLAP tears
SICK scapula and dyskinesia
249
What is the difference between internal impingement and external impingement (subacromial)?
Subacromial or "external" impingement occurs on bursal side of rotator cuff.
Internal impingement occurs on the articular side.
Caused by repetitive impingement of posterior under-surface of supraspinatus tendon and greater tuberosity.
Pathologic micromotion of the humeral head allows the rotator cuff to become impinged between the greater tuberosity and the glenoid.
250
When does internal impingemetn occur?
During maximum arm abduction and external rotation during late cocking and early acceleration phases of throwing.
Causes "peel back" phenomeneon of posterosuperior labrum by biceps.
Major cause of shoulder pain in throwing and overhead athletes.
251
How will a patient with internal impingement present?
What physcial exam findings will they have?
Diffuse pain in posterior shoulder along the posterior deltoid. Worse with throwing, especially during late cocking and early acceleration.
Pain along infraspinatus. Increased external rotation. Decreased internal rotation (**Loss of \> 20 degrees of IR at 90 degrees compared to contralateral shoulder**) Need to stabilize the scapula to get the true measure of glenohumeral rotation.
Often can demonstrate rotator cuff weakness
Provocative tests: Whipple test and Apprehension test.
252
What two provocative tests can be performed to look for Internal impingement?
**Whipple test:** Perfromed to test for partial supraspinatus tears. Performed by ranging shoulder in forward flexion, adduction and scapular retraction. Positive when pain is reproduced on resistance.
**Apprehension test:** Positive for internal impingement. Performed by bringing shoulder into maximum ER, abduction, and extension. Positive if posterior shoulder pain reproduced in this position and releived when arm brough into neutral extension/flexion.
253
Assuming this is an atraumatic injury that occured over time what does this image depict?
Bennett Lesion (exostosis of posteroinferior glenoid)
Seen in internal impingement.
254
What are some of the image findings consistent with internal impingement?
Radiographs may show a Bennett lesion.
MRI or MR arthrogram.
Can show pathology of the rotator cuff and/or labral pathology:
Partial articular-sided supraspinatus-infraspinatus tendon avulsion (PASTA), fraying, or tear.
Signal at greater tuberosity and/or posterosuperior labrum.
255
Treatment for internal shoulder impingement?
256
When performing a posterior release during arthroscopy of a shoulder for internal impingement syndrome what nerve is at risk?
Axillary nerve is at risk during posterior release at the inferior border of infraspinatus.
257
What are the various eponyms for Brachial Neuritis?
Parsonage-Turner Syndrome
Scapular winging whn long thoracic nerve involved.
Neuraligc amyotrophy (HNA) or idiopathic neuralgic amyotrophy (INA)
Acute brachial neuropathy/ neuritis/ plexopathy /plexitis
Idiopathic brachial plexus neuropathy/ neuritis
258
What are the associated conditions with GIRD of the shoulder?
**Glenohumeral instability**
**Internal impingement-** abutment of the greater tuberosity against the posterosuperior glenoid durign abduction and external rotation leads to pinching of posterosuperior rotator cuff.
**Articular-sided partial rotator cuff tears-** tensile failure in excessive rotation
**SLAP lesion-** throwers with GIRD are 25% more likley to have a SLAP lesion. Peel-back mechanism (biceps anchor and posterosuperior labrum peels back) during late cocking. Because of posterosuperior translation of humeral head and change in biceps vecor force posteriorly.
259
What change in motion must be present before there are deranged kinematics in glenohumeral internal rotation deficits?
If the loss of internal rotation excees the external rotation gain this leads to derganged kinematics.
Decrease in internal roation is usually greater than a 25 degree difference as compared to non-throwing shoulder.
260
What besides posteroinferior capsule stretching during PT is indicated for GIRD?
Pectoralis minor stretching
Rotator cuff and periscapular strengthening.
90% of young throwers respond to sleeper stretches/PT
10% of older throwers do not respond, and will need arthroscopic release eventually.
261
What bony finding within the shoulder has been found to greatly increase the risk of posterior instability?
Patients with increased glenoid retroversion (17 degrees) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (7 degrees).
262
Treatment for posterior labral tears in the shoulder?
PT, NSAIDs, and activity modification firs tline of treatment for all.
If they fail extensive nonop management -\> arthroscopic repair:
More reliable return to play than open. Suture anchor repair an capsulorrhaphy yields best results. **need to prob posterior labrum to rule out a subtle Kim lesion (posterior inferior imcomplete and concealed avulsion of labrum)**
Avoid adduction and internal rotation in the acute postoperative period.
263
What are the complications with posterior labral repair?
Overtightening of posterior capsule can lead to anterior subluxation or coracoid impingement.
**Axillary nerve palsy-** Posterior branch of the axillary nerve is at risk during arthroscopic stabilization. Travels within 1 mm of the inferior shoulder capsule and glenoid rim. At risk during suture passage at the posterior inferior glenoid.
264
What runs above the suprascapular ligament?
suprascapular artery
265
What do you do if you suspect suprascapular neuropathy based on physical exam and EMG but there is no compressive cyst or mass on MRI?
Activity modification and shoulder rehab for a minimum of 6 months.
Only consider surgical nerve decompression at suprascapular notch after extened therapy and persistent symptoms of a year.
Most common cause of neuropathy of suprascapular nerve is actually a traction injury produced by a tretraced superior or posterior cuff tear. (45% of volley ball players will have this to some degree).
266
What is more common medial or lateral scapular winging?
Describe each?
Medial scapular winging.
Type of scapular winging is defined by direction of the superomedial corner of the scapula.
**Medial-** dysfunction of serratus anterior (long thoracic nerve) leads to excessive medializing scapular retraction (rhomboid major and minor) and elevation (trapezius). usually in a young athletic patient.
**Lateral-** Dysfunction of the trapezius (cranial nerve XI- spinal accessory nerve) excessive lateralizing scapular protraction (serratus anterior, pectoralis major and minor). Usually iatrogenic (history of neck surgery)
267
What is the origin and insertion of the serratus anterior?
Innervation?
Different parts and functions?
Originates from ribs 1-8 and inserts on anteromedial border of scapula. Total of 7-10 slips.
Long thoracic nerve
UPPER: Downward rotation (glenoid down), stabilizes superior scapula
MIDDLE: Scapular protraction
LOWER: upward rotation and abduction
268
What is the origin and insertion of the levator scapulae?
Primary motion?
Innervation?
Originates from C1-C4 transverse processes and inserts onto medial border of scpul at the level of the scapular spine.
Elevation of the scapula and downward rotation to tilt the glenoid cavity inferiorly
Innervated by C3-C4 pelxus with contribution form dorsal scapular nerve.
269
Causes of Medial Scapular Winging?
What is most common?
While they can be mechanical such as traumatic avulsion of the serratus anterior or displaced fractures of the inferior pole of the scapula. The vast majority are neurologic and there are several different causes. Please see image.
## Footnote
**Repetitive stretch injury is most common!**
270
Treatment for medial scapular winging?
Observation and PT for minimum of 6 months but ideally 18 months to 2 years. Wait for nerve to recover. **majority of patients will spontaneously resolve with full return of shoulder function and resolution of winging by 2 years.**
Early repair if serratus anterior avulsion.
Neurolysis of the long thoracic nerve if no improvement after 6 months and EMG shows nerve compression (distal latency, dennervation) **Supraclavicular decompression as the nerve traverses the scalene muscles.**
Split pectoralis major transfer if no improvement at 1-2 years and there is good pain relief and improved shoulder function with manual scapular stabilization.
Developing technique is nerve transfer. Either lateral branch of the thoracodorsal nerve or medial pectoral nerve with sural graft to the long thoracic nerve.
Last option is Scapulothoracic fusion in those with persistent pain and failure of treatments above.
271
What are some of the causes of lateral scapular winging?
Injury to the spinal accessory nerve (CN XI) through one of the following:
**Iatrogenic-** most common. Injury in the posterior traingle of th eneck during cervical lymph node biopsy and radical neck dissection.
**traumatic-** traction injury (sudden laterla flexion of the neck with motor vehicle or motorcycle accidents). Blunt trauma can even occur during deep tissue massage. Penetrating injury to the neck.
272
Treatment for lateral scapular winging?
Conservative treatment more controversial given it is most often an iatrogenic cause.
If elderly and sedentary without identifiable injury then should initially be treated conservatively.
Predictors of poor outcome with conservative management include inability to raise the arm avove the shoulder at presentation and dominant extremity involvement.
Exploration of the psinal accessory nerve, neurolysis, and repair.
Muscle transfer: Eden-Lange transfer. Transfer of the levator scapulae and rhomboid muscles from the medial border of the scapula to the lateral border to effectively reconstruct the trapezius.
273
274
What are the two clinical types of brachial neurtis?
**Idiopathic neuralgic amyotrophy-** Unclear etiology, likely multifactorial with autoimmune, genetic, infectious, environmental, and biomechanical processes all playing a role.
**Hereditary neuralgic amyotrophy-** Very rare. 200 families worldwide. Autosomal dominant. Mutations in the gene Septin 9 on chromosome 17q24. Cytoskeleton protein highly expressed in glial cells in neuronal tissue.
DIFFERS FROM IDOPATHIC FORM: Dysmorphic features (short stature, hypotelorism, cleft palate, facial asymmetry, unusual skin folds).
Higher inicidence of recurrent episodes. Younger age of onset. Frequent involvement of nerve outside the brachial plexus. More severe paresis. Worse functional outcomes.
275
What are the demographics of Parsonage-Turner Syndrome?
Males \> Females
Middle Age (4th Decade) ages 20-60 most common.
Unilateral involvement more common. Bilateral 10-30% of patients (16% simultaneously)
276
What is the pathoanatomy of Brachial Neurtis?
What is the Pathophysiology?
Any nerve or branch within the brachial plexus can be involved. Nerves outside the brachial plexus are affected in 17% of cases. Nerve most commonly affected: Long thoracic, suprascapular, axillary, musculocutaneous, radial, and cervical nerve roots.
Multifactorial: Autoimmune- increased blastogenic activity of lymphocytes. Transform to larger more active lymphocytes when in contact with brachial plexus tissue. Increasaed complement-fixing antiboides to peripheral nerve myelin.
Biomechanical- mobility of the upper turnk predisposes to wear and tear on the blood nerve barrier. Repetitive mobilization may disrupt.
277
What are risk factors for Brachial Neuritis?
**Infection-** viral infections 25-55%: EBV, Varicella-zoster, Coxsackie B, parvovirus B19, CMV, mumps, smallpox, HIB
Bacterial infections: Leptospira, TB, Yersinia, Salmonella, Borrelia burgdorferi
**Immunizations-** Tetanus, hepatitis B
**Stress-** perioperative and peripartum (14%) Strenuous exercise (8%), burns.
**Drugs-** abacavir, streptokinase, heroin, infliximab, interferon
**Iatrogenic-** interscalene block, surgery, lumbar punctures, irradiation
278
What is the prognosis of brachial neuritis?
66% have recovery of motor function within 1 month.
Recovery rated "excellent" in 36% at 1 year, 75% at 2 years and 89% at 3 years.
**May take up to 8 years for full recovery of stregth.**
Recurrence is rare in non-hereditary cases
Factors associated with poor prognosis: female gender, lower trunk involvement. Upper has best prognosis. Persistent pain and no motor function recovery by 3 months. Hereditary cases
**Age has no effect on prognosis.**
279
What are the three phases of brachial neuritis?
**Phase I:** Sudden onset of severe, unrelenting shoulder pain. Radiates to the proximal arm and/or neck. Primary symptom in 90% of cases. Lasts days to weeks.
**Phase II:** Painless flaccid paralysis. Begins within 24 hours (33%) to 4 weeks (80%). Most commonly involves the upper brachial plexus and usually more than one nerve branch. **Often will see differential involvement of muscles innervated by the same nerve (PATCHY PARESIS).**
**Phase III:** Slow recovery. Slow and steady return of motor function over 6-18 months. Duration over the recovery phase is often directly proportional to duration of pain phase at onset.
280
What studies or tests are diagnostic of Brachial Neuritis?
May show elevated liver enzymes, positive antiganglioside antibodies, and positive antinuclear antibody (ANA) test.
MRI: T2 will show diffuse singal hyperintensity within muscles innervated by the brachial plexus but doesn't have to be all of them.
T1: may show focal intamuscular signal intensity (fatty infiltration) and atrophy of the involved muscles.
EMG: Early (3-4 weeks) Acute dennervation with positive sharp waves and fibrillation potentials in both periphera nerve and nerve root distributions.
Late (3-4 months) Chronic dennervation and early reinnervation with polyphasic motor unit potentials.
281
Treatment for Brachial Neuritis (Parsonage-Turner Syndrome).
Obervation and pain control. Especially during the early pain phase. NSAIDs, oral corticosteroids ( two week course of 1mg/kg/day followed by a two week taper, Slow release narcotics, and immobilization.
PT once severe pain has abated and weakness is the primary issue.
Nerve exploration, neurolysis, neurorraphy (direct nerve repair), nerve grafting, nerve transfer or muscle/tendon transfers:
Only when no evidence of regeneration or early recovery in a nerve distribution by 6-9 months on physical examination and EMG studies. **Neurolysis alone was superior to neurorrhaphy and nerve grafting.**
282
What is thoracic outlet syndrome?
Patient demographics?
Most common type?
Neurovascular disorder resulting from compression of the brachial plexus and/or subclavian vessels in the interval between the neck and axilla.
Females \> males (3:1). Tend to be thin with long necks and drooping shoulders. Age 20-60
Neurogenic is most common (95%)
Vascular may be venous (4%) or arterial (\<1%) More common in athletic males compares to athletic females.
283
What is the soft tissue pathoanatomy of thoracic outlet syndrome?
Most cases are thought to stem from anatomic predisposition with superimposed neck trauma (acute or chrnoic repetitive stress. **70% are soft tissue abnormalities.**
**Scalene muscle abnormalities-** hypertrophy, passage of the brachial plexus through the anterior scalene muscle. Scalenus minimus. Accessory muscle found in 30-50% of patients with TOS. Originates from cervical tp and inserts onto 1st rib between the subclavian artery and T1 root.
**anomalous ligaments or bands-** fibromuscular bands. Costoclavicular ligament. Abnormal insertionimplicated in Paget-Schroetter syndrome.
**Soft tissue tumors-** Pancoast tumor of the pulmanry apex. neuroblastomas, schwannoma of the brachial plexus.
284
What is Paget-Schroetter syndrome?
Type of venous thoracic outlet syndrome seen in well-developed young athletes.
Intermitten obstruction of the subclavian vein in the costovlavicular space by **abnormal costoclavicular ligament** and/or anterior scalene muscle hypertrophy
results in upper extremity deep vein thrombosis.
285
What is the osseous pathoantomy of thoracic outlet syndrome?
Osseous abnormalities only 30% of the time compared to 70% soft tissue.
**Cervical rib:** occurs in \<1% of the population. Arise from the 7th cervical vertebra (four types). Prominent C7 TP.
**Abnormal clavicle or first rip-** acute fracture displacement. Hypertrophic fracture callus formation. Fracture malunion.
**AC or SC joint injury or dislocation**
**osseous tumors**
286
What are the three distinct spaces of thoracic outlet syndrome?
**Interscalene triangle-** contains brachial plexu trunks and subclavian artery.
**costoclavicular space-** contains brachial plexus divisions and subclavian artery and vein
**retropectoralis minor space-** contains brachial plexus cords and axillary artery and vein.
287
Presentation of a patient with thoracic outlet syndrome?
very variable.
92% have trapezius pain.
Can have uuper extremity weakness, numbness, and parestheias. Upper extremity heaviness.
Activity related pain and night-time sympotms.
Venous (cyanoti discoloration and swelling of the limb) and Arterial (unilateral Raynaud-type symptoms)
**Gilliatt-Sumner hand-** characteristin finding of neurogenic TOS. atrophy of the abductor pollicus brevis, hypothenar muscles, and interossei.
288
Provocative tests for thoracic outlet syndrome?
289
Imaging studies to evaluate thoracic outlet syndrome?
Radiographs and CT to look for boney abnormalities and space occupying lesions.
MRI for soft tissue anomalies
Nerve conduction studies. C8 and T1 may show early changes in neurogenic TOS. Abnormal nerve conduction velocites in the medial antebrachial cutaneous nerve and median motor nerve to the abductor pollicis brevis.
Doppler ultrasound- very helpful for evaluating subclavian vein for obstruction and thrombosis.
Angiography to work up embolic disease of suspected arterial aneurysm. Venography to work up suspected subclavian or axillary venous thrombosis.
290
Treatment for thoracic outlet syndrome?
First line is activity modification, PT, and pain control.
Can attempt anterior scalene blocks. Succesful block is a good prognostic indicator of surgical outcomes.
Those that have failed conservative treatment for 6 months -\> thoracic outlet decompression.
Most common procedure is first rib resection, anterior and middle saclenectomy, neurolysis. 95% good outcomes.
Vascular intervention for embolic events, stenosis, subclavian aneurysm, thrombosis with critical ischemia.
291
What is the most common complication of operative treatment for thoracic outlet syndrome?
Pneumorthorax, assuming they had a first rib resection.
Multiple approaches: transaxillary, supraclavicular, and posterior.
For the most common procedure (first rib resection, anterior and middle scalenecotmy, and neurolysis) a combined approach is usually required?
TRANSAXILLARY- to access first rib and lower plexus
SUPRACLAVICULAR- to access anterior and middle scalene muscles and upper plexus
292
What is the incidence, demographics, location, and risk factors of quarilateral space syndrome?
INCIDENCE: rare and often misdiagnosed as subacromial impingement.
DEMOGRAPHICS: 20-40 years old
LOCATION: most commonly affects the dominant shoulder
RISK FACTORS: overhead movement athletes. Contact or throwing sports.
**Greatest amount o fcompression occurs when the arm is positioned in the late cocking phase of throwing.**
293
What are the borders of the Quadrilateral Space?
Triangular Space?
Triangular interval?
294
What are the contents of the quadrilateral space?
Acillary nerve.
Posterior circumflex humeral artery.
295
What may you see on imaging of a patient with quadrilateral space syndrome?
MRI- artrophy of teres minor (axillary innervation). Compression of quadrilateral space (see image). May show inferior paralabral cyst that is associated with a labral tear.
ARTERIOGRAM- may show lesions in posterior humeral circumflex artery.
EMG- used to confirm the diagnosis and will show axillary nerve involvement.
296
Treatment for quadrilateral space syndrome?
NSAIDs, PT, and activity restriction. Focus on glenohumeral joint mobilization and strengthening, posterior capsule stretching, and massage. **Most people improve with 3-6 months of nonoperative treatment.**
Diagnostic lidocaine block will help to confirm the diagnosis 2-3cm interior to the standard posterior shoulder arthroscopy portal.
Nerve decompression. Often with labral repair as a paralabral cyst is often the cause of compression.
297
Is osteoarthritis of the shoulder more common in women or men?
women
298
Where is classic glenoid wear in Rheumatoid arthritis?
Osteoarthrits?
Central
Posterior wear. Will also see subchondral cyst formation.
299
What are the causes of proximal humerus AVN and their incidence?
Traumatic?
Atraumatic?
Proximal humerus fracture: 35% in 3 part. 90% in 4 part.
Chronic gelnohumeral dislocations, repetitive injury, and rotator cuff repair.
ATRAUMATIC: steroid, ETOH, hemoglobinopathies, metabolic (e.g. Gaucher's disease)
300
Is there a higher incidence of rotator cuff tears in osteoarthritis or rheumatoid arthrtis?
5-10% with OA
25-50% with RA
301
What has been associated with proximal humerus chondrolysis?
Occurs following shoulder arthroscopy.
Radiofrequency energy. Continuous postop anesthetic infusion. Bioabsorbable suture anchors. Contrast.
Will see less osteophytes than in OA
302
What is the normal anteversion or retroversion of the glenoid and the humerus.
Glenoid is 3 degrees retroverted
Humerus is 20-30 degrees retroverted
303
What is a shoulder CAM procedure?
CAM- comprehensive arthroscopic management procedure.
Combination of arthroscopic glenohumeral debridement, chondroplasty, synovectomy, loose body removal, humeral osteoplasty with excision of the goat's beard osteophyte, capsular releases, subacromial and subcoracoid decompressions, axillary nerve decompression, and biceps tenodesis.
304
What are the associated conditions with adhesive capsulitis?
Both types of diabetes- worse outcomes regardless of treatment. Increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI.
Thyroid disorders.
Dupuytren's disease.
Atheroslcerotic disease.
Cervical disc disease.
305
What are the clinical states of adhesive capsulitis?
**Freezing/painful-** gradual onset of diffuse pain (6 wks to 9 mos)
**Frozen/Stiff-** Decreased ROM affecting activities of daily living (4 to 9 mos or more)
**Thawing-** Gradual return of motion (5 to 26 mos)
306
What finding on physical exam is the most specific to Adhesive capsulitis?
Symmetric loss (regarding planes of motion) of both passive and active ROM
307
What is the recommended treatment for adhesive capsulitis?
PT, NSAIDs, +/- intra-articular steroid injections, heat and/or cryotherapy. Should be supervised for 3-6 months. Should be gentle and stop at the point of pain.
Can do MUA. Controversy of when to do this. Only 50% success in diabetics.
Arthoscopic capsular release: Indwelling catheter for regional anesthesia often used to aid in therapy.
**Release rotator interval from anterior biceps tendon to superior edge of subscap. Coracohumeral ligament can then be visualized and released. Posterior capsular release. Subacromial bursectomy and adhesions released as needed. No acromioplasty done. MUA can be done after.**
308
True or false: The most common outcome for patients treated with physical therapy and stretching for adhesive capsulitis is decreased shoulder ROM compared to the contralateral shoulder.
True even though the majority of patients have acceptable resolution of symtpoms they still have some loss of motion.
309
What is the ASEPTIC mneumonic used for regarding avascular necrosis of the shoulder?
**A**lcohol, **A**IDS
**S**teroids (most common), **S**ickel, **S**LE
**E**rlenmeyer flask (Gaucher's)
**P**ancreatitis
**T**rauama
**I**diopathic/**I**nfection
**C**aisson's (the bends)
310
What is the dominant blood supply to the humeral head?
What else supplies blood to the humeral head?
**Posterior humeral circumflex artery**- Provides 65% of blood supply.
Ascending branch of anterior humeral circumflex artery and arcuate artery.
**Arcuate**- the interosseous continuation of ascending branch of anterior humeral circumflex artery and penetrates the bone of the humeral head.
**Ascending branch of anterior humeral circumflex artery-** vessel runts parallel to lateral aspect of tendon on long head of biceps in the bicipital groove.
311
What is the most common initial site of avascular necrosis in the humeral head?
Superior middle portion of humeral head.
312
What is the treatment of avascular necrosis of the humeral head?
Normal x-rays and changes on MRI: Initially PT and conservative care. If no improvement then core decompression and arthroscopy ( confirm the integrity of cartilage)
If a crescent sign without collapse then humeral head resurfacing.
Collapse -\> Hemiarthroplasty.
313
What is scapulothoracic dyskinesis?
What are the causes?
What is the pathoanatomy?
**Also known as SICK scapula**
Abnormal scapula motion leading to shoulder impingement and dysfunction.
Neurologic injury, pathologic thoracic spine kyphosis, periscapular muscle fatigue, poor throwing mechanics, secondary to pain (shoulder, neck)
Scapulothoracic power imbalance leads to protraction of scapula -\> leads to alteration of mechanics at glenohumeral joint. Excessive stress placed on anterior capsule of shoulder and posterosuperior labrum.
Athletes have increased risk of injuring labrum, rotator cuff, and capsule.
Scapula may be lower and protracted as seen in image.
314
What is treatment recommended for SICK scapula?
Also known as scapulothoracic dyskinesis.
NSAIDs, PT, local injections.
PT to focus on: core strengthening, scapular stabilizers, serratus anterior, trapezius, rotator cuff muscles.
Coordination of scapular motion with trunk and hip movements.
**This is often a sequela of prior shoulder injury that leads to SICK scapula.**
315
How do you determine implant heigh of hemiarthroplasty?
Greater tuberosity should be 5 to 8mm below the top of the prosthetic humeral head.
Functions to maintain cuff and biceps tension. Recreate normal contour of medial calcar.
Cement prosthesis proud. Distance from prosthesis head to upper border of pectoralis major should be 56mm.
**Cementation is standard of care.** Provides better quality of life, ROM, and strength compared to uncemented humeral component.
316
In a patient with osteoarthritis of their shoulder that has failed conservative treatment and an isolated full thickness tear of their supraspinatus what surgical intervention for definitive treatment should be recommended?
TSA
isolated supraspinatus tear without retraction can proceed with anatomic instead of reverse.
Incidence of full thickness cuff tears in patients getting a TSA is 5% to 10%.
If there are positive impingement sings on exam, order a pre-operative MRI.
317
What are the general outcomes of TSA?
More predictable pain relief and benefit than hemiarthroplasty.
10 year survival 93%
Reliable range of motion.
Worse results for post-capsulorrhaphy arthropathy
318
Regarding Gelonoid components in TSA what is the recommendation for the following:
Convex vs flat
Peg vs Keel
All polyethylene vs metal-backed
Uncemented vs cemented
Conforming vs nonconforming
Convex
Peg design
All Poly
Uncemented glenoid has a lower rate of loosening
Both conforming and nonconforming have advantages and neither is superior. Confroming is more stable but leads to rim stress and radiolucencies.
Nonconfroming leads to increased polyethylene wear.
319
What should the position of the humeral stem be in a TSA?
Should be in 25-45 degrees of retroversion.
If position of glenoid retroversion is required, then the humeral stem should be less retroverted to avoid posterior dislocation.
320
What is the most common complication after TSA?
Glenoid loosening (30% of primary OA revisions)
2.9% reoperation rate for loosening (28% with revision)
Presence of radiographic lines does not correlate with symptoms.
Presence of radiographic lines does not correlate with symptoms.
Progression of a radiographic line does correlate with symtpoms. Progression present in 50% of patients as early as 3 to 4 years after TSA.
**Radiolucency around the glenoid does not always correlate with clinical failure.**
321
In what disease processes is humeral stem loosening more common in TSA?
RA and osteonecrosis.
322
What is another approach besides the deltopecotral that can be used for reverse total shoulder arthroplasty?
What are the advantages and disadvantages?
**Anterosuperior-** Deltoid is divided from the anterior edge of the acromioclavicular arch, allowing increased glenoid exposure.
**Advantages-** Increased glenoid exposure, preserves subscapularis, decreased post-op instability. Ease of axial preparation of the humerus. Easier fixation of greater tuberosity for fractures.
**Disadvantages-** Increased risk of injury to distal brnches of axillary nerve. Violates deltoid muscle. Risk of excess height or superior tilt of glenoid.
323
In proximal humerus fractures treated with RTSA, what motion is least predictabel in its return?
External rotation.
Anatomic Greater tuberosity repiar is important to restore proper shoulder rotation.
324
What is the most common mechanism of failure for a reverse total shoulder arthroplasty?
What are other common modes of failure and their incidence?
**Glenoid loosening (Most common cause after two years)**. Treated with a staged procedure where the glenoid is grafted and a hemi placed until incorporation has taken place and a new glenosphere can be placed.
Dislocation (2-3.4%). risk factors: irreparable subscap (strongest risk factor), proximal humerus bone loss, failed prior arthroplasty, proximal humeral nonunion, and fixed pre-operative glenohuermal dislocation.
Deep Infection 1-2%. **Most common reason for revision within the first two years after surgery.**
325
How often does scapular notching occur after RTSA?
What are the risk factors?
Can occur in 44-96% of grammont style prosthesis. Decreased incidence with lateralization of baseplate. Related to impingement by the medial rim of the humberal cup during adduction
RISK FACTORS:
Superior placed glenoid component
Superior tilt of glenoid component
Medialization of center of rotation
High BMI
**Want as much inferior tilt and inferiorly located base plate as possible.**
326
What is the new name for propionibacterium acnes?
Cutibacterium acnes.
Gram-positive, facultative, aerotolerant, anaerobic rod that ferments lactose to propionic acid
Concentrated in the axilla within the dermal sebaceous glands.
Forms biofilm within 18-90 hours. Aspiration is only 17% sensitive
Mean duration of culture incubation between 7-21 days.
**Clindamycin for C. acnes prophylaxis.**
327
What are risk factors for a shoulder prosthetic joint infection?
Smoking
Young age, male gender
Revision surgery
Arthroplasty for trauma
Inta-articular steroid injection within 3 months of surgery
Postoperative hematoma
328
True or false: All bacteria from a biofilm on implants by 4 weeks?
True some form even if not clinically significant.
329
True or false: A patient with C. Acnes prosthetic shoulder infection may have normal CRP and ESR. They will usually not have any swelling, erythema, fever, or purulent discharge?
True
330
How often are synovial tissues cultures positive in shoulder prosthetic infections?
How many should be obtained?
How long should cultures be held for?
80%
4 specimens
14-28 days for C. acnes. 4 weeks for fungal. 8 weeks for mycobacterial.
Cultures should be on aerobic, anaerobic, and broth media.
331
For shoulder prosthetic infections:
What is the success rate of debridement and prosthesis retention in acute infections?
Resection arthroplasty?
50%
Functional results are poor. Leave tuberosites and cuff . Pain relief is achieved in more than 50%.
332
What depth of rotator cuff tears should be converted and repaired for bursal side and articular side?
\> 3mm bursal surface
\> 6mm articular surface.
Tears on the bursal surface are felt to be less well-tolerated because they are on the highest tension side.
333
What radiograph is the best for visualizing hill sachs defects?
Stryker notch view.
obtained by positioning the patient supine with the arm flexed toward the celining, flexed at the elbow, and the patient's hand placed on top of the head and the xray beam is directed anteroposterioly with 10 degrees of cephalic angulation.
334
Group the following tests with the elbow stability (valgus, PLRI, and VPMI) that they are most specific too.
Valgus stress, lateral pivot-shift test, gravity-assisted varus stress test
Milking maneuver, posterolateral rotatory drawer test, modified milking maneuver, and chair push-up test
Moving valgus stress test, prone push-up test, and table-top relcoation test.
**Valgus Instability:**
Valgus stress test
Milking maneuver
Modified milking maneuver
Moving valgus stress test
**PLRI:**
Lateral pivot-shift test
Posterolateral rotatory drawer test
Chair push-up test
Prone push-up test
Table-top relocation test
**VPMI:**
Gravity-assisted varus stress test
