Upper Extremity

Question 1

1. ) What injuries are associated with late cocking/early acceleration?
2. ) What injuries are associated with deceleration?

Answer 1

1. ) SLAP tears and internal impingement

2. ) Posterior supraspinatus/anterior infraspinatus

Question 2

If being treated operatively - what do you do for:

1. ) Medial winging
2. ) Lateral winging

Answer 2

1. ) Split pec major transfer

2. ) Eden-Lange = Levator & Rhomboid

Question 3

What location does a sublabral foramen typically exist? And what do you do with it?

Answer 3

12-3 o’clock, anterosuperior
DON’T repair! Gets tight in ER!!
…if also have chord-like MGHL -> Buford complex!

Question 4

What is anterior dislocation recurrence chance in young and military?

Answer 4

~90%!!

Question 5

What is a HAGL and what is the treatment?

Answer 5

Humeral avulsion of the glenoid ligament
Treat w/ surgery! -> may fix open if anterior or posterior may fix arthroscopically (anterior can be done w/ scope too…more common to do open though)

Question 6

In first time shoulder dislocators, who will you offer surgery?

Answer 6

< 22 yo, contact athletes, military, bony bankhart

Open stabilization vs arthroscopic NO difference

Question 7

What are the 2 main nerves at risk during Laterjet procedure?

Answer 7

1. ) MC injury -> Musculocutaneous (due to retractor placement while harvesting coracoid)
2. ) Axillary nerve while fixing to glenoid

Question 8

How do you treat tears in:

1. ) Rotator cable
2. ) Rotator crescent

Answer 8

1. ) Fix it!

2. ) Nonop - doesn’t really matter

Question 9

What is the most sensitive test for Subscap tear?

Answer 9

Bear hug (patient puts hand on contralateral shoulder and is told to keep hand there w/ shoulder in IR…examiner then tries to ER by lifting hand off of shoulder w/ patient resisting)

Question 10

What is the typical distance of the acromiohumeral interval?

Answer 10

8-10 mm

Question 11

How do you treat RTC tear that is:

1. ) Massive tear
2. ) Acute full-thickness tear in young pt
3. ) Chronic full-thickness tear

Answer 11

1. ) Fix it!
2. ) Fix it!
3. ) PT first -> 6-12 wks, if doesn’t get better then surgery!

Question 12

What is the difference in fixing a RTC with double vs single row?

Answer 12

NO DIFFERENCE (unless a really large tear, you may want a double row)

Question 13

What is the comma sign and in what setting does it occur?

Answer 13

Avulsed SGHL being pulled medially by a retracted subscap tear (note: tail of the comma points to the subscap)

Question 14

What are contraindications to Superior Capsular Reconstruction?

Answer 14

1. ) Arthritis

2. ) Irreparable posterior and/or subscap cuff tears

Question 15

In regards to TSA:

1. ) How is it better than a hemi?
2. ) What is the #1 postop problem?
3. ) If you have subscapularis failure - what do you do?

Answer 15

1.) In every way!!
2.) Glenoid loosening
3.) Early (< 6 weeks): Repair!
Late (> 6 weeks): convert to rTSA

Question 16

What 2 main patient populations should you think about doing a hemiarthroplaty in?

Answer 16

1. ) Young patient (< 50 yo) w/ AVN

2. ) Young pt w/ bad humerus fx and ability to fix GT

Question 17

How do you prevent notching in rTSA?

Answer 17

1. ) Inferior placement of sphere
2. ) Inferior tilt
3. ) Increase lateral offset
4. ) Increase glenosphere
   * *Notching leads to polywear and osteolysis w/ potential for baseplate wear!

Question 18

How did the Grammont shoulder design change the center of rotation of the native shoulder?

Answer 18

1. ) Medialized & Distalized the center of rotation! (note: even when you “lateralize” the glenosphere, it is still overall medialized compared to normal anatomy) -> medial helped decrease stress on implant and distal helped tension deltoid
2. ) Humerus is lowered more relative to the acromion which tensions the deltoid more

Question 19

A decrease in deltoid abduction force in a rTSA can be achieved by…

Answer 19

Medializing the glenosphere COR

Question 20

What are the Pro’s of a lateralized glenoid design (still overall medialized from anatomic) for rTSA?
What are the Con’s?

Answer 20

Pros:
1,) Increased impingement free ROM
2.) Deltoid and posterior cuff more tensioned -> increased forward elevation and ER
3.) Better stability
Cons:
1.) More stress at bone/implant interface
2.) Increased risk of scapulospine/acromial stress fx -> treat nonop in sling x 6 wks! (make sure heals though b/c need deltoid which is attached to all this bone!!)

Question 21

What is the most common bacteria to cause PJI after TSA or rTSA? What else do you worry about?

Answer 21

Staph aureus is MOST COMMON!

But still hold Cx for at least 14 days b/c worry about P. Acnes

Question 22

In an elderly person with a non-reconstructable proximal humerus fracture - should you do a hemi or a rTSA?

Answer 22

rTSA!!!

Question 23

For thrower’s shoulder with internal impingement, what is the treatment?

Answer 23

Try non-op tx for 3-6 months!

If fail that -> try arthroscopic debridement; try to AVOID RTC repair!!! (b/c they don’t often get back to throwing!)

Question 24

What qualities in the patient with a SLAP tear would you consider repair in? (3)

Answer 24

Isolated Type 2 SLAP
< 35 yo w/ traumatic origin
Overhead thrower
OTHERWISE consider tenotomy vs tenodesis!

Question 25

1. ) What is the “essential lesion” of adhesive capsulitis?

2. ) What direction do you lose ROM the most?

Answer 25

1. ) Coracohumeral ligament (CHL), Rotator Interval, Capsule
2. ) External rotation

Question 26

When performing an arthroscopic release of the rotator interval for adhesive capsulitis, what ligament must be visualized to ensure adequate depth of the rotator interval resection?

Answer 26

Coracoacromial ligament

Question 27

Which part of the SC joint is most important for AP stability?
For medial stability?

Answer 27

Posterior capsule

Costoclavicular ligament

Question 28

What is the treatment for Lat Dorsi avulsion?

Answer 28

Non-op

Question 29

1. ) What is the treatment for 1st time Stinger/Burner?

2. ) What is the treatment for 2nd time?

Answer 29

1. ) RTP when no symptoms (which should be in seconds)

2. ) Hold from play until have workup -> C-spine XR

Question 30

1.) What can cause suprascapular neuropathy? 2.) And what are the 2 most common locations?

Answer 30

1. ) Cyst or scar tissue/traction…this is the cause if don’t see cyst on MRI (COMMON IN VOLLEYBALL PLAYERS!)
2. ) Suprascapular notch, Spinoglenoid notch

Question 31

1. ) What borders make up the quadrilateral space?

2. ) What structures are in the quadrilateral space?

Answer 31

1. ) Superior is teres minor, inferior is teres major, and medial/lateral is the longhead/lateral head of the tricep
2. ) Posterior circumflex humeral artery, axillary nerve

Question 32

1. ) What is the cause of medial scapular winging?
2. ) What is the initial treatment for medial scapular winging?
3. ) What is the surgical treatment for medial scapular winging?

Answer 32

1. ) Injury to long thoracic nerve -> serratus anterior (traction injury)
2. ) Rehab -> wait 12-18 months to see if recover!
3. ) Pec major transfer (clavicular head) to inferior scapula

Question 33

1. ) What is the cause of lateral scapular winging?

2. ) What is surgical treatment?

Answer 33

1. ) CN IX nerve injury -> trapezius (usually iatrogenic during cervical dissection)
2. ) Eden Lange Transfer = transfer of the levator scapulae and rhomboid laterally

Question 34

1.) What are the possible treatments for snapping scapula syndrome?

Answer 34

1. ) PT
2. ) Injection
3. ) Arthroscopic bursectomy of the superomedial angle