Shoulder Flashcards
AC joint injury classification scheme
Type I injuries involve purely an AC joint sprain with intact CC ligaments. Type II injuries involve complete tearing of the AC joint and a sprain of the CC ligament with the CC measurement being < 25% greater than of the contralateral shoulder. Type III, IV, V, and VI injuries all involve complete tearing of both the AC and CC ligaments. Type III injuries have a CC distance measurement between 25 and 100% greater than that of the contralateral side (this patient) compared to Type V injuries which have a CC distance > 100% of the contralateral side. Type IV and VI injuries represent posterior and inferior dislocation of the clavicle, respectively. The coracoacromial ligament is generally spared in these injuries
AC joint modified weaver-dunn reconstruction complications
distal clavicle resection, coracoacromial ligament transfer, and augmentation (modified Weaver-Dunn
does not restore native stability to AC joint. **Persistent horizontal (A to P) instability may cause persistent symptoms. **Anatomic repair and recon that preserve distal clavicle offer less risk of horizontal instability
innervation to the AC joint
Supara scapular nerve posteriorly
Lateral pectoral nerve anteriorly
Tx for AC joint injuries
Type: I-II nonop, good functional outcomes. full rehab 6-12 weeks
Type III: controversal, good results and return to sport for athletes
Type IV,V, VI surgery
The importance of the ACLC to joint stability: The ACLC is critical for ? stability. and is compromised with ?
The importance of the ACLC to joint stability has been highlighted in multiple studies. The ACLC is critical for anteroposterior stability and is compromised with distal clavicle excision
Which examination test is most specific for pain related to AC joint osteoarthritis?
Cross body adduction test: pain w/ shoulder in 90 FF and max adduction across body
cross-body adduction test is the most sensitive provocative test for AC joint osteoarthritis at 77%, the O’Brien active compression test has been shown to be most specific at 95%. CSI injection, only 44% accurately enter the joint.
Most common complication following distal clavicle excision? Appropriate amount of distal clavicle excision?
Persistent pain is the most common complication following distal clavicle excision. Although the exact amount of distal clavicle that should be resected is a topic of debate, resection of 10 mm or more of the distal clavicle may lead to instability of the AC joint, especially if the AC capsule is sectioned.
Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision?
Examination of the GH jt allows examination of SLAP tear which could mimic AC jt pain. Arthroscopic DCE sacrifices the inferior AC ligament and preserves the superior AC ligament.
What ligaments provid the most restraint to the AC joint?
Posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. (Distal clavicle excision)
The deltotrapezial fascia becomes confluent with which portion of the AC joint capsule, providing additional stability?
The musculotendinous aponeurosis of the deltotrapezial fascia interdigitates with the superior acromioclavicular joint capsule. The deltotrapezial fascia is believed to have synergistic stabilizing features with the capsule.
Zanca views to evaluate AC joint injuries
Bilateral Zanca views are obtained with 10-15° of cephalad tilt in the AP orientation with 50% penetrance
Risk factors that predispose an individual to rotator cuff tear and affect healing include
age, smoking, sex (female), family history, diabetes mellitus, and high cholesterol
The risk of partial-thickness tears enlarging at 2 and 5 years is ??, respectively, whereas full-thickness tears have a ?? risk of enlarging of at 2 and 5 years, respectively. Fatty infiltration and degeneration?
The risk of partial-thickness tears enlarging at 2 and 5 years is 11% and 35%, respectively, whereas full-thickness tears have a 22% and 50% risk of enlarging of at 2 and 5 years, respectively.
Muscle degeneration is associated with full-thickness tears rather than partial-thickness tears. Fatty degen more common in older pts and larger baseline tears. RCT w/ fatty degen are more prone to enlarge over time.
?% of rotator cuff tendon repairs do not heal; healing is affected by patient age, tendon retraction, and fatty muscle infiltration, with most failure occurring during ?
25% of rotator cuff tendon repairs do not heal; healing is affected by patient age, tendon retraction, and fatty muscle infiltration, with most failure occurring during active rehabilitation (2 to 3 months postoperatively)
clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?
a painful arc with active range of motion is common
impingement signs are usually positive,
lift-off test is normal.
Active and passive range of motion measurements are often equal, although active range of motion can be painful.
External rotation lag signs are often seen with larger full-thickness tears.
The usual presentation of traumatic subscapularis tears is most often seen after forced
forced external rotation: The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.
What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint?
Concavity compression is a stabilizing mechanism by which muscular compression of the humeral head into the glenoid fossa stabilizes the glenohumeral joint against shear forces. This is dependent on the depth of the concavity and the magnitude of the compressive force.
What is the most consistent finding regarding glenohumeral kinematics in patients with symptomatic tears of the rotator cuff?
Superior translation of the humeral head with more than 30 degrees of abduction
Normal glenohumeral kinematics are represented by ball-and-socket modeling when the rotator cuff is intact. This is true for motion that involves more than 30 degrees of abduction. In patients with shoulder pain and symptomatic rotator cuff tears, superior translation occurs with abduction beyond 30 degrees. This is quite evident in massive tears but is seen consistently to a lesser degree with smaller tears.
Patients over 40 with initial anterior dislocation
Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.
A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients.
Most common location for cuff tears
The most common location of rotator cuff tears is the junction of the supraspinatus and infraspinatus tendons, approximately 13 to 17 mm posterior to the biceps within the rotator crescent. This area is known to be a critical zone of hypovascularity, predisposing it to degenerative tears. The vascularity of this area also decreases with age, suggesting that the increasing incidence of rotator cuff tears with age is not related to chronic abrasive wear but to decreasing vascularity and degenerative changes.
Impingement syndrome: tx outcomes surgery vs PT
Nonsurgical management also has been shown to be as effective and less expensive than surgical subacromial decompression with acromioplasty. If bony impingement caused by acromial spurring was the cause, physical therapy alone, with no modification of the bony architecture, would not be expected to lead to outcomes similar to those of acromioplasty
impingement syndrome caused by an acromial spur, as proposed by Neer, is not the primary process that explains the origin of most degenerative rotator cuff tears.
Inflammatory markers elevated in subacromial bursitis
Several inflammatory markers have been shown to be elevated in subacromial bursitis. These include metalloproteases, tumor necrosis factors, and cyclooxygenase 1 and 2.
Calcific tendonitis:
what are the 3 stages? What is deposited in the tendon? Symptomatic? How does it appear on imaging? Tx?
- precalcific, calcific (3), and postcalcific
- deposition of calcium phosphate crystals (hydroxyapatite) within the rotator cuff tendon.
- 35% do not have symptoms, so evaluate pts for other symptoms
- 1.5-2 cm from insertion, On MRI, calcium deposits appear hypointense on all sequences.
On ultrasonography, calcium deposits appear hyperechoic.
Tx: Nsaids, PT, CSI. 27 percent failure rate at 6 months associated w/ b disease, larger deposits adn extension of calcification medial to acromial. .
USguided neddling to aspirate and then inject saline or steorid into lesion (UGNL) relief at 1 year, 5 year outcomes showed equal in comparison to CSI in SA alone. Arthroscopic debridment for recalcitrant disease
The precalcific stage generally is pain free; fibrocartilaginous metaplasia of tenocytes into chondrocytes occurs predominantly in less vascular areas of the tendon.
Calcific stage characterized by foci of calcium deposition; often separated by septae.
The resorptive phase typically is the most painful, directed by inflammatory response involving macrophages and multinucleated giant cells.
Pt has right shoulder pain over GT and Neer Hawkins impingement, dx and initial mgmt
Subacromial impingement: Initial management should consist of stretching exercises directed at the posterior capsule and a program of rotator cuff and deltoid strengthening exercises performed below the horizontal in a ‘safe’ plane. The judicious use of subacromial cortisone injections (one or two) may be helpful. Anterior acromioplasty is reserved for patients who have failed to respond to nonsurgical management.
Dislocation of the long head of biceps
Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice.
Initial postoperative management after repair of an acute rotator cuff tear includes
In the immediate postoperative period following repair of an acute rotator cuff tear, passive forward elevation and external rotation should be performed within the safe zone determined at surgery. Early active range of motion (prior to tendon healing), internal rotation behind the back, and resistive exercises increase the risk of rupture of the repair.
Hx of extensive extensive arthroscopy debridement and synovectomy, Examination reveals a golf ball-sized swelling just lateral to the coracoid. The area is not warm and shows no other signs of infection. An MRI scan is shown in Figure 1. Management should now consist?
Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality.
Functional Improvement after revision RCR is most likely to occur in
Functional improvement after revision rotator cuff surgery is most likely to occur in patients with an intact deltoid, good-quality rotator cuff tissue, preoperative active elevation alone to 90 degrees, and only one prior rotator cuff repair.
what part of the labrum has the least vascularity
Anterior/Superior
glenoid labrum receives its blood supply from the suprascapular, posterior humeral circumflex, and circumflex scapular arteries. The labral vessels arise from the capsular and periosteal vessels that penetrate the periphery of the labrum. The bone does not appear to be a source of vascularity. The posterior/superior and inferior labrum have a fairly robust vascular supply, whereas the anterior/superior labrum has relatively poor vascularity, which may influence the success of superior lateral repairs.
Anatomic Variation of the glenoid labrum and MGHL in the anterosuperior quadrant of the shoulder, what’s the most common?
- Labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the most common “normal” variation. 86.6%
Wide variations in the anatomy of the anterosuperior portion of the labrum and the middle glenohumeral ligament have been reported and are more common than previously thought. The labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the most common “normal” variation. A cord-like middle glenohumeral ligament is often associated with the presence of a sublabral hole. An anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and no labral attachment to bone is the configuration of the Buford complex. The prevalence of each variation from one recent study is as follows: #1: 86.6%; #2: 3.3%; #3: 8.6%; and #4: 1.5%.
Atraumatic neuropathy of the suprascapular nerve usually occurs at what anatomic location?
Suprascapular and spinoglenoid notches
The suprascapular nerve passes through the suprascapular notch and the spinoglenoid notch before innervating the infraspinatus muscle. At both locations, the suprascapular nerve is prone to nerve compression, which often results from a ganglion cyst. The other anatomic locations are not associated with suprascapular nerve impingement
With increasing abduction in the scapular plane, maintaining neutral rotation, contact area, and contact pressure per unit area between the humeral head and glenoid follows what pattern if the total load across the joint is held constant?
- glenohumeral joint becomes more congruent at higher levels of abduction.
- contact area increases and contact pressure decreases
- As the load is spread more evenly across the joint, contact pressure per unit area decreases as long as the total load across the joint is held constant.
Which of the following ligaments are the primary static restraints to inferior translation of the arm when the shoulder is in 0 degrees of abduction and neutral rotation? Mid range of Abduction? 90 degrees of abduction?
Superior glenohumeral and coracohumeral
midrange = MGHL
90 = infereior GHL
Biomechanical ligament sectioning studies have implicated both the superior glenohumeral and coracohumeral ligaments as restraints to inferior translation when the shoulder is in 0 degrees of abduction and neutral rotation. Although there is controversy over the significance of each ligament, both are involved to some degree. The middle glenohumeral ligament is more important in the midranges of abduction, and the inferior ligament is more important at 90 degrees of abduction. The coracoacromial and coracoclavicular ligaments play no role in glenohumeral restraint.
Long Thoracic Nerve injury? What nerve roots? What does it cause?
- Injury (from axillary dissection or aggressive retraction of the middle scalene muscle) results in serratus anterior palsy and **medial winging of the scapula **(superior elevation of the scapula with medial translation and medial rotation of the inferior pole of the scapula).
- C5-7
The long thoracic nerve arises from the anterior rami of the C5 through C7 nerve roots to innervate the serratus anterior muscle. It is located on the superficial surface of the serratus anterior muscle, making it susceptible to injury, which may result in characteristic medial winging of the scapula.
To avoid damage to the ascending branch of the anterior humeral circumflex artery during open reduction and internal fixation of a proximal humeral fracture, the blade plate should be placed in what position?
Lateral to the bicipital groove and pectoralis major tendon
The pectoralis major tendon inserts lateral to the biceps tendon, which runs in the bicipital groove. The primary vascular supply of the articular surface of the humeral head is derived from the anterior circumflex humeral artery, which continues into the arcuate artery once it enters the bone. The entry point is on the anterolateral aspect of the humerus just medial to the greater tuberosity within the bicipital groove. To avoid compromising circulation, the blade plate should be placed lateral to the bicipital groove and pectoralis major tendon insertion.
Most important structure preventing SC dislocation?
posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
arrow is pointing at what artery?
axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
Axillary Nerve:
Branch of? Nerve roots? Where does it exit? Branches? When is it at risk?
- Branch of posterior cord, C5-6
- closest to the glenoid labrum at the 6-o’clock position on the glenoid, at a mean of 12 mm.
- exits quadralateral space (w/ posterior humeral circumeflex)
- provides abduction of arm b/t 30-90 degrees
3 branches:
* Posterior (teres minor and posterior and lateral deltoid area skin) superior lateral brachial cutaneous n,
* anterior (deltoid), 5 to 6 cm distal to the midlateral acromial margin.
* articular branch (innveration to GH jt)
quadrilateral space (medial: long head of the triceps; lateral: humeral shaft; superior: teres minor; inferior: teres major)
muscular branch supplying the teres minor lies closest to the glenoid labrum and is most susceptible to injury during arthroscopic capsular procedures.
anterior branch to the deltoid is located 5 to 6 cm distal to the midlateral acromial margin; however, it can be as close as 3 cm. This distance is positively correlated with limb length; it is reduced by as much as 30% with abduction of the arm to 90°.
MSC Nerve
- Lateral cord C5-7
- main trunk penetrates the coracobrachialis muscle 3 to 8 cm distal to the tip of the coracoid.
- innervates the biceps brachii and the brachialis
- terminates as the lateral antebrachial cutaneous nerve to the anterolateral forearm.
It then travels deep to the biceps brachii but superficial to the brachialis before it emerges as the lateral antebrachial cutaneous nerve and provides sensation to the anterolateral aspect of the forearm. During its course, the musculocutaneous nerve provides motor innervation to the coracobrachialis, biceps brachii, and brachialis.
Suprascapular nerve: root? sites of compression and what does that compression result in? Where is the nerve at risk of injury?
- Upper trunk C5-6
- Two possible sites of compression are the **suprascapular notch **and the spinoglenoid notch.
- 1.5 cm medial to the posterior rim of the glenoid and can be endangered in this location with transglenoid fixation techniques.
- innervates the supraspinatus and infraspinatus muscles.
- Suprascapular nerve compression at the suprascapular notch causes denervation of the supraspinatus and the infraspinatus. Nerve compression at the spinoglenoid notch leads to selective denervation of the infraspinatus muscle.
Spinal Accessory Nerve (Cranial Nerve XI)
- Injury from cervical lymph node biopsy or radical neck dissection results in trapezius palsy and lateral winging of the scapula (depression of the scapula with lateral translation and lateral rotation of the inferior pole of the scapula).
The spinal accessory nerve (cranial nerve XI) innervates the trapezius, which attaches to the acromion, scapular spine, and clavicle. Subsequent injury to the spinal accessory nerve may result in lateral winging of the scapula.
Scapula Dyskinesia: how to examine for it? lateral vs medial scapular winging?
Lateral scapular winging is defined by excessive lateral rotation or increased distance between the borders of each scapula. Medial scapular winging is defined by a prominent inferior scapular tip with asymmetric medial prominence during shoulder motion. To aid in the diagnosis, relief of symptoms via manual medial stabilization can be performed. Assessment of the gross muscle bulk of the serratus anterior and trapezius also should be noted because they may contribute to medial and lateral scapular winging, respectively
Baseball pitchers who have internal impingement will most likely demonstrate what changes in range of motion?
- Pitchers tend to have a decrease in internal rotation and an increase in external rotation. decrease IR increase ER
- increase in external rotation is felt to be multifactorial.
- An increase in humeral retroversion occurs from repeated throwing. This results in increased soft-tissue stretching and results in a posterior capsular contracture.
best imaging for SLAP tears
MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct.
posterior dislocation, what position to avoid after reduction?
Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks.
Acute posterior dislocations occur rarely, accounting for less than 5% of acute dislocations. They are most often the result of falls on an outstretched hand. Reduction can be accomplished with flexion of the arm to 90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is then externally rotated until the head has cleared the glenoid rim. Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks.
A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?
Long thoracic?
Spinal Accessory?
Thoracodorsal?
The long thoracic nerve C567, which innervates the serratus anterior, is prone to injury because of its superficial location along the chest wall.
The spinal accessory nerve innervates the trapezius, and the thoracodorsal nerve innervates the latissimus dorsi. The
Normal acromiohumeral interval distance? What numbner is considered pathognomoinc for rotator cuff tear? What are findings consistent advanced cuff tear arthropathy?
Normal 7-14, less than 14 is radiographic marker for cuff disease
* Acetabularization of the acromion, rounding of the greater tuberosity, and femoralization of the humeral head are signs of advanced rotator cuff arthropathy that can be appreciated on shoulder radiographs.
* Chronic rotator cuff insufficiency may result in anterosuperior escape (migration of the humeral head through the rotator interval). This results from failure of the subscapularis and/or supraspinatus (rotator interval lesion).
arrow demonstrates?
A, Normal infraspinatus muscle (arrow). B, Fatty infiltration of the infraspinatus muscle (arrow).
LHB tendon best visualed on what view?
The LHB tendon is best visualized on axial MRIs.
Medial dislocation of the LHB out of the bicipital groove may indicate a subscapularis tear
Axial T2- weighted MRI of a shoulder shows medial dislocation of the biceps tendon (arrowhead), an empty bicipital groove (short arrow), and a subscapularis tear (long arrow).
Humeral avulsion of the inferior glenohumeral ligament (HAGL), is best visual on what MRI view? What if they present delayed? Pathognomic sign for hagl?
Humeral avulsion of the inferior glenohumeral ligament (HAGL)
Best visualized on coronal oblique T2-weighted, fat-suppressed MRIs acutely postinjury
- Consider magnetic resonance arthrography in patients with a delayed presentation
- J-sign on MRI is considered pathognomonic for HAGL
MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in
MRI scan reveals a posterior labral detachment. This injury is the result of a posteriorly directed force and is common to football players in blocking positions. Although this injury can occur with trauma in all types of athletes, it is seen with relative frequency in football. Treatment is aimed at labral repair with posterior capsulorrhaphy. Both open and arthroscopic techniques can be used.
A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 1. What is this finding? What is the surgical tx?
open repair of the lateral joint capsule disruption.
The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high.
Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?
Adduction and external rotation
Following anterior dislocation of the shoulder, the affected arm is typically placed in a sling with the shoulder in adduction and internal rotation. A recent study has shown that placement in this position actually results in laxity of the anterior supporting structures of the shoulder, allowing the postinjury hemarthrosis to push the labrum and capsular ligaments away from the anterior glenoid rim. Thus, immobilization in this position may actually impede healing of these structures. Alternatively, resting the arm in a position of adduction and external rotation allows the anterior supporting structures to abut against the anterior glenoid rim by forcing the hemarthrosis posteriorly. Placing the arm in this position following anterior dislocation is believed to allow for better healing of the anterior labrum and ligaments.
What radiographic view is used to assess humeral bone loss following glenohumeral joint dislocation?
Stryker Notch
- Evaluate Hill-Sachs lesion after dislocation
- With patient supine, the affected arm is placed on the top of the head with the fingers toward the back of the head; beam is centered over coracoid process with 10° cephalic tilt
What radiographic view aids in the assessment of glenoid bone loss?
West Point view
How is the radiographic beam directed and what is the patient position for the West Point view to evaluate glenoid bone loss?
Patient is prone with the involved shoulder raised above table level, centered on axilla with beam directed 25° downward and 25° medial
Tendon transfer options for functionally irreparable RC tears, best for what pathology and outcomes?
* Latissimus dorsi
* Lower Trap
* Pect minor
* combine lat and teres major
* Pect major
* anterior lat dorsi?
Lati Dorsi tendon transfer is best for?
Young patients with an intact subscapularis/teres minor and active elevation greater than 80° are ideal surgical candidates
Latissimus dorsi tendon transfer is a surgical treatment option associated with favorable clinical and functional outcomes for irreparable posterosuperior rotator cuff tears.Latissimus dorsi tendon transfer can reduce humeral head migration and restore external rotation in patients with an irreparable posterosuperior rotator cuff tear. The tendon has a potential excursion of 33 mm.73 The transfer itself is associated with excellent strength and posterior force couple but exhibits poor synergism.
Combined Latissimus Dorsi and Teres Major Tendon Transfer
- Latissimus dorsi tendon and teres major tendon transfer is associated with satisfactory outcomes, with functional gains in external rotation in patients with a posterosuperior FIRCT and brachial plexus palsy
Poorer outcomes are associated with a nonfunctional subscapularis. - transfer combination also may be performed in the setting of reverse total shoulder arthroplasty with an external rotation lag sign.
Pectoralis Major Tendon Transfer
- Pectoralis major tendon transfer provides an** internal rotation centering force for irreparable subscapularis tears**; however, reported outcomes reveal mixed results
- Latissimus dorsi, teres major, and lower trapezius tendon transfers can be performed to manage irreparable
- Pectoralis major, pectoralis minor, and anterior latissimus dorsi tendon transfers can be performed to manage irreparable
- posterosuperior rotator cuff tears.
- anterosuperior rotator cuff tears.
first step in mgmt for psuedoparalysis and RCT
Physical therapy focusing on anterior deltoid strengthening
Collin and associates and Levy and associates have demonstrated significant functional improvement for treatment of CTA with pseudoparalysis with physical therapy. These studies found average improvement of active forward elevation from 40° to 160° when successful. Factors associated with physical therapy failure were rotator cuff tears involving 4 tendons or 3 tendon tears thatdo not allow for recentering of the humeral head.
massive cuff tear, young patient/laborer, no OA, xamination of the right shoulder shows forward elevation to 115 degrees, external rotation at the side to 10 degrees and internal rotation to the lower thoracic spine. He has a negative belly press and lift off test and positive hornblower’s and external rotation lag signs.
His chronic posterosuperior cuff tear in the setting of young age and an intact subscapularis makes him a candidate for a latissimus dorsi tendon transfer to improve the patient’s function and pain.
A pectoralis major transfer would be appropriate for a chronic subscapularis tear and in this case the patient’s is intact based on physical exam findings.
Superior Capsular Reconstruction (SCR) indicated for? More successful outcome sin?
Indications for superior capsular reconstruction (SCR) include intractable pain and dysfunction who have failed conservative treatments with massive irreparable rotator cuff tears, typically of the supraspinatus and infraspinatus tendons. More successful outcomes have been associated in patients with minimal to no rotator cuff arthropathy (Hamada Stage 1 or 2), an intact or reparable subscapularis tendon and an intact deltoid muscle.
Age has not been defined as a specific contraindication to performing SCR.
Those with Grade 3 of Goutallier Classification have 50% rotator cuff muscle/fatty degeneration. This makes primary rotator cuff tear more difficult and prone to failure but is not a contraindication to SCR.
- Normal insertional anatomy is not restored after RCR. The enthesis is replaced by?.
- Torn rotator cuff tendon has ?
- Normal insertional anatomy is not restored after RCR. The enthesis is replaced by disorganized scar tissue with impaired mechanical properties after repair.
- Torn rotator cuff tendon has low cellularity, poor blood supply of the enthesis, and degenerative changes
Timing of RCR failure
- 3-6 months after repair
- Re-tear rates ranged from 17% to 41%, all of which occurred within the first 6 months after RCR
Kim Test
Posterior instability, posteroinferior labral lesion
Kim test is more sensitive for posterior-inferior labral tears and is elicited by pain with forward flexion of the shoulder to 45 degrees while simultaneously applying axial load on the elbow, and posterior-inferior force on the upper humerus. When both the Jerk and Kim tests are combined, the sensitivity in diagnosis of a posterior labral tear increases to 97%.
jerk test
applying a posterior force along the axis of the humerus with the arm in forward flexion and internal rotation, which in effect causes the humeral head to subluxate posteriorly and causes a clunk.
Jerk test was more sensitive in detecting a primarily posterior labral lesion.
Kim test is more sensitive for posterior-inferior labral tears and is elicited by pain with forward flexion of the shoulder to 45 degrees while simultaneously applying axial load on the elbow, and posterior-inferior force on the upper humerus. When both the Jerk and Kim tests are combined, the sensitivity in diagnosis of a posterior labral tear increases to 97%.
Distal Clavicle Osteolysis:
whats the cause? 1st line? surgery? complication of surgery? Theory to cause?
- repetitive stress and micro-fractures leading to bone resorption, common in weightlifters
- A trial of rest, NSAIDs, physical therapy and modified weightlifting technique (avoiding manoeuvres with the elbows posterior to the torso) have shown to be successful in mitigating symptoms.
- open or arthroscopic distal clavicle excision if non op fails
- arthroscopic DCE (mumford): can address GH and other pathology, quicker recovery and return to activity
- resect on .5-1 cm of DC, too large leads to AC jt instability
- Complication: horizontal instability: avoid violating posterior superior capsule or it will lead to horizontal instability
theory of overhead and weightbearing activities having an important role in the development of distal clavicle osteolysis.
MDI (multidirectional shoulder instability) definition and diagnosis? exam findings? Treatment? Surgery?
- generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy.
- dx: presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased external rotation
- Treatment is a trial of prolonged physical therapy focusing on** dynamic stabilization and periscapular muscle training**.
- Arthroscopic stabilization with capsular shift is indicated for patients with persistent instability who fail an extensive course of physical therapy.
sulcus sign: assesses rotator interval, represents inferior laxity,
laxity of rotator interval presents as increased ER w/ arm fully adducted and at 90degrees of abducted
MDI:
* 2 underlying mechanisms?
* Pathoanatomy Hallmark findings?
* referred to as AMBRI?
- Microtrauma from overuse: overhead throwing, volleyball, swimmers, gymnasts
- generalized laxity, EDS and marfans
- MRI: patulous inferior capsule on MRI (IGHL anterior and posterior bands)
- Rotator interval deficiency
- Atraumatic, Multidirectional, Bilateral (frequently), Rehab (often responds to), Inferior capsular shift (best alternative to non op)
mage demonstrates a capacious and redundant posterior capsule.
signs of generalized hypermobility - generalized ligamentous laxity = Beighton’s criteria >4/9
- able to touch palms to floor while bending at waist (1 point)
- genu recurvatum (2 points)
- elbow hyperextension (2 points)
- MCP hyperextension (2 points)
- thumb abduction to the ipsilateral forearm (2 points)
MDI surgery?
Arthroscopic image of a shoulder shows a patulous capsule with an expanded inferior pouch. The glenoid is below, and the humeral head is above.
must address capsule +/- rotator interval
* inferior capsular shift (capsule shifted superiorly)
* plication of redundant capsul
* rotator inveral closure (open or closed)
RI closure produces the most significant decrease in range of motion in external rotation with the arm at the side 0 degrees. Plicating anterior superior region of capsule by suturing superior and middle glenohumeral ligaments together
Traumatic Anterior shoulder instability
TUBS
recurrence rate correlates w/?
mechanism of injury?
Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery
- high recurrence rate that correlates with age at dislocation. up to 80-90% in teenagers (90% chance for recurrence in age less than 20)
- anteriorly directed force on the arm when the shoulder is abducted and externally rotated
In young patients (less than 25 years old), recurrence rates have ranged from 60-94%. Family history confers a 34% risk of recurrence, while dislocation in the contralateral shoulder is seen in 25% of recurrently unstable patients according to one study in JBJS (Hovelius et al, 2008).
TUBS ontrack vs off track concept of Hillsachs lesion
- Hill-Sachs defect is “off-track” and will “engage” on the glenoid if the size of the Hill-Sachs defect > glenoid articular track (HSI > GT)
- Hill-Sachs defect is “on track” and will NOT “engage” if the size of the Hill-Sachs defect < glenoid articular track (HSI < GT)
Glenoid Track (GT) = 0.83D-d (D = diameter of inferior glenoid, d = width of anterior glenoid bone loss) Hill-Sachs Interval (HSI) = HS+BB (HS = width of the Hill-Sachs, BB = width of bony bridge)
TUBS associated injuries?
Brankart lesion: is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid. present in 80-90% of patients with TUBS
Humeral avulsion of glenohumeral ligament:
Glad: glenoid labral articular defect sheared off articular cartilage with labrum, high risk factor for failure after arthroscopy
anterior labral periorsteal sleeve avulsion
Fractures and bone defects:
Bony bankart: fx of anterior inferior glenoid
**Hill-sachs: **chondral impaction of posterior superior humeral head secondary to contact w/ glenoid rim. Present in 80-100% of traumatic dislocations and 25% of subluxations
97% of patients with recurrent instability have either a Bankart or ALPSA lesion
What is this finding? What is seen on radiographs? What should you suspect? Tx in recurrent instability?
Glenoid hypoplasia
radiographs show glenoid hypoplasia. The common radiographic findings of glenoid hypoplasia include an inferior and posterior glenoid deficiency, enlargement of the distal end of the clavicle, and sometimes an indentation in the glenoid. It is usually bilateral and rarely associated with other syndromes; therefore, an echocardiogram, abdominal ultrasound, or a skeletal survey is unnecessary unless the patient has stigmata of a syndrome such as Holt-Oram or Apert’s. Although posterior instability has been reported, the results of glenoid osteotomy have been variable and should not be considered initially. Physical therapy is the mainstay of initial management, but the patient should be counseled that this may be a recurrent problem with early osteoarthritis developing in many patients. Radiographs of the contralateral side should be obtained because this is usually bilateral.
Athlete with subluxation event, symptoms of instability and this MRI. Tx?
Recent clinical studies have suggested that early stabilization of initial anterior dislocations may lead to better results than nonsurgical management in young, athletic patients. However, there are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder. If the athlete cannot return to play following nonsurgical management, surgical repair of the labrum, either through an open or arthroscopic approach, is indicated.
35 y/o w dislocation, Examination reveals anterior and inferior apprehension that reproduces her symptoms. Tx?
open repair of the lateral joint capsule disruption.
The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability.
internal impingement
throwing and overhead athetes
diffuse pain in posterior shoulder along deltoid, worse w/ throwing
Exam: decreased IR loss of more than 20 degrees at 90 compared to contralateral side, increased ER
humeral head allows the rotator cuff to become impinged.
impingement during max abduction, external rotation late cocking, and early acceleration phase.
peel back phenomenon by posteriorsuperior labrum
hypertrophy and scarring of posterior capsule glenoid (Bennett lesion)
tightness of posterior band of IGHL
Tx: PT cessation of throwing, posterior capsular stretching
- athroscopic debridment of cuff and labrum for PASTA, Bennet lesions, and peel back labral lesions if non op fails
xray of a bennet lesion.
spectrum of injuries: fraying of the articular side of posterior cuff (supraspinatus-infraspinatus interval),posteriorsuperior labral lesions, bennett lesion,
MRI may show partial articular-sided supraspinatus-infraspinatus tendon avulsion (PASTA), fraying, or tear
GIRD
Glenohumeral internal rotation deficit (GIRD) 18° difference in internal rotation compared with the contralateral extremity.
decrease in IR, increase in ER, sulcus sing (stretching of anterior structure that resist er (CH ligament and rotator interval)
tx: rest from throwing and PT for 6 months, sleeper stretch (IR stretch at 90 abd w/ scapular stabilization)
* tightening of posterior capsule or posteroinferior capsule leads to translation of humeral head (capsular constraint mechanism)
* translation of humeral head is in the OPPOSITE direction from area of capsular tightening
* posterior capsular tightness leads to anterosuperior translation of humeral head in flexion
* posterorinferior capsular tightness leads to posterosuperior translation of humeral head in ABER
* Associated conditions: GH instability, internal impingment, PASTA, slap slesions
* throwers w/ GIRD are 25% more likely to have a slap lesion
- peel back mechanism (biceps anchor and postero superior labrum peels back during late cocking because postero superior translation of humeral head and change in biceps force postriorly.
Throwing phases:
Max forced is placed during ?
Most injuries occur in what phase?
Force is transferred from the ground reaction forces through a stable base with mainly lower extremity movement during wind up.
Maximal stress is placed on the shoulder in late cocking/early acceleration, during which the shoulder approaches maximal external rotation. The scapula is retracted, the elbow is flexed, and the humerus is in abduction and external rotation. The subscapularis, pectoralis major, and latissimus dorsi are eccentrically contracting to stabilize the joint. Most shoulder injuries occur in this stage.
The acceleration phase is characterized by scapula protraction, humeral adduction, and internal rotation (force produced by the subscapularis, pectoralis major, and latissimus).
Deceleration results in glenohumeral distraction and shear forces, with eccentric loading of the posterior rotator cuff and considerable biceps and brachialis activation to slow elbow extension.
Peel back mechanism
When the arm is in the 90-90 position, the biceps tendon is shifted more posteriorly (because of external rotation), and the biceps anchor subsequently twists. This places a torsional force on the superior labrum.
Although this is a normal adaptation for throwing athletes, it may become pathologic if the anchor becomes unstable
Sick Scapula
A SICK scapula manifests with the involved shoulder appearing anterior and inferior (protracted), coracoid tenderness, and dyskinesis.
Scapular malpositioning—The scapula protracts, rotating about a horizontal axis, with the upper scapula rotating anteroinferiorly; the shoulder appears lower than the contralateral side.
Inferior medial border prominence
Coracoid pain and malpositioning—Contraction of the pectoralis minor and the short head of the biceps contribute to the coracoid tilting inferiorly and laterally away from the midline.
Dyskinesis—Decreased subacromial space leads to external impingement and rotator cuff weakness.
**AAOS: In the static evaluation of the athlete’s shoulder, a SICK scapula is characterized by which of the following scapula positions: Inferior, protraction, anterior tilt, inferior angle prominence
Early in the condition, substantial deficits in range of motion and form (kinetic chain) may be noted before the onset of symptoms. Failure to address these factors early may lead to worsening dysfunction and increased risk for intraarticular damage.
Baseball player, adolescent with this xray? What is it and next steps?
Little Leaguer’s shoulder, physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis.
tx: rest from throwing activities. cessation of throwing, then PT and progressive throwing program after sufficient rest.
OB:
repetitive torsional & distractive stresses at physis SHI. Hypertrophic zone (weakest portion of physis) Late cocking: 400% greater external rotatory force than physis can tolerate. Deacceleration: excessive eccentric stress
Breaking pitches implicated
# of pitches most important factor
Complication: Premature growth arrest of proximal humeral epiphysis
prevention: proper pitching mechanics, discourage breaking ball pitches, enforcement of pitch counts, avoid year round pitching.
A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 1 through 3. Management should consist of
arthroscopic repair and decompression.
The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear.
Sick Scapula Syndrome: what is it and how does it present?
- Scapular malpositioning
- Inferior medial border prominence
- Coracoid pain and malpositioning
- Dyskinesis of scapular movement
- Exam:
- Scapular retraction test—Manually retract the scapula with the palm or forearm placed on the scapula and fingers over the coracoid; decreased pain and improved strength with supraspinatus testing
- Scapular assist—Pain with shoulder elevation is reduced if the inferior scapula is manually assisted in abduction or elevation
Related to scapular dyskinesis, which is the dynamic manifestation of this disorder
Presents as anterior shoulder pain in the dominant arm of the throwing athlete, often with dead arm complaints
The characteristic feature of this syndrome is the involved shoulder appearing to be lower than the contralateral shoulder (because of scapular protraction)
Typical physical examination findings in someone with scapular dyskinesis include?
Optimal rehabilitation for scapula dyskinesis should focus on?
- Tenderness at coracoid and subacromial space, weak core strength exam, (+) scapula assist test, (+) scapula retraction test
- Improving core strength, improving glenohumeral internal rotation deficit, stretching the pectoralis minor, and strengthening the serratus and lower trapezius
Altered kinematics of the scapula on dynamic use falls into three clinically recognizable patterns of scapular dyskinesis.
Type 1: inferior medial scapular prominence; associated with labral pathology.
Type 2: medial scapular prominence; associated with labral pathology.
Type 3: superomedial border scapular prominence; associated with external (subacromial) impingement and rotator cuff pathology rather than labral pathology
entr
Posterior Labral tear “Reverse bankart”
demographics?
pathology?
anatomy of posterior labrum?
clinic symptoms and exam manuevers?
athroscopic treatment if non op fails requires?
complications of athroscopic tx?
- Weightlifters, lineman (bench press, blocking)
- repititive microtrauma to posterior capsulolabral complex, posterior directed force w/ arm flexed, IR, and adducted
- Kim lesion: incomplete avulsion of posteroinferior labrum
- posterior labrum anchors posterior inferior glenohumeral ligament (PIGHL)
- vague, nonspecific posterior shoulder pain worsen with push/bench, clicking and popping
- exam: posterior apprenhesion, posterior load-shift, **jerk test clunk highly sensitive **, kim test shoulder abd 90 ff45 w/ posterior inferior force, highly sensitve/spef for posteroinferior labral tear
- non op: activity mod, nsais, PT
- athroscopic labral repair capsullorrhaphy, suture anchor repair + capsullorrhaphy fewer recurrences and revisioncs than non anchored repairs, must probe posterior labrum to r/o subtle kim lesion.
Complications of surgery: axillary nerve palsy, posterior branch of axillary n, travels 1mm off the inferior shoulder capsule and glenoid rim, at risk during suture passage
overtighting of posterior capsule, leads to anterior subluxation or coracoid impingement
Quadrolateral space syndrome:
anatomy of the space?
mechanism?
greatest compression occurs with the arm in what position?
clinical symptoms and exam?
What will an MRI show?
Diagnosis?
Non op vs op?
- causes: iatrogenic (tight fibrous bands, muscular hypertrophy), paralabral cysts (most commonly inferior labral tears), trauma, masses
- Contents: axillary nerve (C5 nerve root, posterior cord), posterior circumflex humeral artery
- arm is positioned in the late cocking phase of throwing (abduction and external rotation)
- poorly localized pain to posterior lateral shoulder, worse at night, worse w/ OH activities, or late cocking/accel of throwing, paresthesias long lateral arm.
- external rotation shoulder weakness w/ arm abducted.
- MRI may show atropjy of teres minor (axillary innervation), compression of qualilateral space, inferior paralabral cyst w/ labral tear
- EMG to confirm diagnosis
- diagnostic lidocaine to confirm dx: block 2-3 cm inferior to standard posterior shoulder portal
- Non-op: nsaids, activity restrictions, PT. most improve with 3-6 months of non-op
* nerve decompression if failed non op, weakness and functional disability, space occuppying lesion.
open release of quadrilateral space +/- arthroscopic repair of labral tear
Prognosis: Long-standing cases often causes atrophy/weakness of teres minor and deltoid
Quadrolateral space syndrome:
What will an MRI show?
* MRI may show atropjy of teres minor (axillary innervation), compression of qualilateral space, inferior paralabral cyst w/ labral tear
* EMG to confirm diagnosis
* diagnostic lidocaine to confirm dx: block 2-3 cm inferior to standard posterior shoulder portal
* Non-op: nsaids, activity restrictions, PT. most improve with 3-6 months of non-op
* nerve decompression if failed non op, weakness and functional disability, space occuppying lesion.
open release of quadrilateral space +/- arthroscopic repair of labral tear
Medial vs lateral scapular winging
medial scapular winging: serratus anterior (long thoracic nerve), weak protraction, excessive medializing scapular retraction (rhomboid major and minor) and elevation (trapezius). young athlete more vomon
lateral scapular winging: dysfunction of the trapezius (cranial nerve XI - spinal accessory nerve), weak superior and medializing force on the scapula excessive lateralizing scapular protraction (serratus anterior, pectoralis major and minor). usually iatrogenic
suprascapular notch entrapment causes?
Spinogelnoid notch entrapment casues?
what’s the pathoanatomy?
Exam findings:
Suprascapular nerve (C5-6), emerges off superior trunk
Suprascapular notch: weakness in both supra and infra
Spinoglenoid: weakness in infra.
Slap tears associated more w/ spinoglenoid cyst
Supraspinatus: weakness seen with shoulder abduction to 90 degree, 30 degrees forward flexion, and with internal rotation (Jobe test positive)
Infra: weakness to external rotation with elbow at side
exam: may have Infraspinatus Atrophy along posterior scapula
MRI: posterior labral lesions w/ associated cyst
EMG/NCS: diagnostic
Tx:
Nonop w/ PT if no structural lesion on MRI
Labral repair w/ cyst decompression if labral lesion w/ associated cyst on MRI.
Spinoglenoid ligament release w/ nerve decompression if no structural lesion and failed extended non op management (1 yr)
suprascapular ligament (artery runs above, nerve runs below)
spinoglenoid ligament (overlies distal suprascapular nerve)
Brachial Neuritis (Personage Turner Syndrome)
- severe shoulder pain followed by patchy muscle paralysis and sensory loss involving the shoulder girdle and upper extremity
- Diagnosis is made clinically with a through neurological exam that may vary from moderate motorsensory changes to flaccid paralysis of the upper extremity and can be confirmed by EMG/NCS.
- reatment is observation and pain control with recovery taking up to 3 years. Operative nerve exploration, neurolysis, nerve transfer or tendon transferbe be indicated if there is no evidence of EMG recovery by 9-12 months.
- 2 clinical types: idiopathic neuralgic amyotrophy (INA) (this topic)
hereditary neuralgic amyotrophy (HNA)
poor prognosis: femail, lower trunk (upper has best prognosis), persistent pain and no motro function recovery by 3 months, hereditary causes
age has no effect on prognosis
Timing of recovery: 66% have recovery of motor function w/in 1 month
- exellent in 36% at 1 year, 75% at 2 years, 89% at 3 years
Adhesive capsulitis:
Whats the path?
What part of the shoulder is affected?
Associated conditions?
Exam findings?
MRI findings
Tx? PT vs Arthrsocopy. What needs to be arthroscopically release
- fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus
- fibroblasts/myofibroblasts with abundant Type III collagen present
- essential lesion involves the coracohumeral ligament and rotator interval capsule
- DM (I &II) and Thyroid disorders
- Exam: symmetric loss of A and PROM. ER deficit most common, tethered endpoint to motion. Painful throughout arc
- MRI will show loss of axillary recess indicating contracture of joint capsule
- PT:
- Arthroscopic release: rotator interval released from anterior biceps tendon to superior edge of subscapularis, Coracohumeral ligament release, Posterior capsule release willl increase IR and cross body adduction
Axillary nerve injury with capsular release perform inferior release near to glenoid rim
What defines the rotator interval
a triangular region between the anterior border of supraspinatus and the superior border of subscapularis
contains the SGHL and coracohumeral ligament
main bloodsupply to humeral head
posterior humeral circumflex artery, which is the primary blood supply to the humeral head, and most likely to lead to AVN when injured.
provides 65% of the blood supply
A 34-year-old male presents due to concerns that his right shoulder is unstable. To assess for p**osterior shoulder instability, the physician flexes and internally rotates the affected arm and flexes the elbow to 90 degrees. The physician then pushes on the flexed elbow, which causes posterior glenohumeral subluxation. **When the physician extends the patient’s arm, the joint reduces. What is the name of the provocative test being performed?
The **Jerk test **is one of the several tests to evaluate for posterior shoulder instability. The Kim, posterior load and shift, and posterior stress tests are different provocative techniques to evaluate for posterior shoulder instability. In contrast, the Hawkings test assesses for shoulder impingement.
Kim test
performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus.
What is the best treatment option to decrease pain and improve function?
Stemmed hemiarthroplasty
The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. **A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. ** In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
functional results after hemiarthroplasty for 3-4part proximal humerus fx are directly related to?
The radiograph shows **tuberosity malposition. **The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than age 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement.
inferior scapula notching rTSA
inferior scapular notching which preoperative superior glenoid erosion has been associated in the development and is correlated with decreased ROM, strength, and Constant scores.
inferior scapular notching is the most common form and is usually the result of the superior placement of the glenoid component and with inadequate inferior tilt. Rarely does scapular notching necessitate revision surgery, but has been implicated with decreased abduction and flexion ROM, post-operative strength, and patient-reported outcomes compared to patients without notching.
Figures 1 and 2 are the radiographs of a 73-year-old man who was diagnosed with cuff tear arthropathy and underwent reverse shoulder arthroplasty. Two weeks after surgery with the shoulder still in the sling the patient turned suddenly and noted increasing pain and abnormal contour of the shoulder. He went to the emergency department and his radiograph is shown in Figure 3. What is the best definitive treatment option?
Glenoid revision
The patient has the preoperative diagnosis of cuff tear arthroplasty and underwent reverse shoulder arthroplasty. The immediate postoperative radiographs reveal the inferior glenoid is not covered by the glenosphere and the humerus is not centered on the glenosphere. These finding indicate bony impingement between the inferior glenoid and inferior humeral polyethylene. He dislocated easily in the immediate postoperative period indicating impingement rather than tension as the cause of instability. The only effective treatment for would be revision of the glenosphere to completely cover the glenoid and eliminate the bony impingement.
