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Goldstein Shoulder Sport Medicine Flashcards

1
Q

Indications for MRI in shoulder pathology (3)

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

Risk factors for adhesive capsulitis

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

Goldstein Lists (2 decks)

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