Shoulder Flashcards
Adult >40 with shoulder dislocation has high rate of:
rotator cuff tear
Which phase of throwing has highest tensile strain on the cuff?
deceleration phase
Size of supraspinatus footprint
12.7mm on anterosuperior greater tuberostiy. Thus a 50% tear is 6mm long.
Most rotator cuffs occur on this side of the cuff:
articular side. Because articular side is 50% tensile strength of the bursal side.
Which cuff side is most vascular?
Bursal side, therefore more likely to heal
Contents of the rotator interval
SGHL, CHL, capsule
The Rotator Cable
fibers from the CHL, perpendicular to the Supraspinatus,
see a subscap tear and think…
subcoracoid impingement
Massive rotator cuff tear definition
> 5cm, t ypically involving more than 1 tendon
Ellman Classification of Partial Cuff Tears
1: <3mm/<25%
2: 3-6mm/25-50%
3. >6mm/>50%
subclassified as A (articular) B (bursal) or I (intradentinous)
Goutallier Classification
Cuff Atrophy
- Normal tissue
- some fatty streaks
- more muscle than fat
- more fat than muscle
Night pain in a rotator cuff tear suggests:
worse non-operative otucomes
Medial biceps tendon subluxation suggest:
Subscapularis tear
Tangent sign:
supraspinatus atrophy. Does not cross a line between the scapular spine and the coracoid on the sagittal MRI
What %age of asymptomatic patients >60 have a RCT?
55%
What size bursal sided cuff tear needs repair?
> 25%
msut be treated more aggressively than articular sided tears
What size aritcular sided cuff tear needs repair?
> 50% (PASTA lesion)
if less than this and failing PT, can do a selective subacromial decompression and debridement. Has a 5% failure rate
Best treatment for irreparable posterosuperior tears with intact subscap?
latissimus dorsi transfer
best in a young laborer
most common cause of RCR failure is:
failure to heal, causing suture pullout from the repaired tissue
Does early vs delayed motion affect outcomes of Rotator cuff repair?
no difference in clinical outcomes or healing with early vs delayed motion protocols. PT and guided early ROM exercises do not reduce stiffness one-year post-operatively
TUBS Means:
traumatic unilateral dislocations with a Bankart requiring surgery.
one of the most common shoulder injuries
Shoulder instability recurrence rates related to age:
90% chance of recurrence in patients <25 years old
Avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid
Bankart lesion
HAGL Lesions:
occurs in patients slightly older than those with Bankart lesions, but much less common than Bankart
treatment = open repair
Anterior labral periosteal sleeve avulsion (ALPSA)
issue is the labrum can heal medially along the medial glenoid neck
Hill-Sachs defect
chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim
- seen in 80% of traumatic dislocations and 25% of trumatic subluxations
- clinically significant if it engages the glenoid
% Glenoid bone loss considerations for surgical management of instability:
<20% glenoid bone loss can be managed with arthroscopic Bankart repair
>20% bone loss requires glenoid augmentation such as open coracoid transfer
Failure risks for arthroscopic bankart repair:
- inverted pear shape glenoid
- engaging Hill-Sachs lesion
67% recurrence in all, 89% recurrence in athletes… therefore contact athletes require open surgery and bone-block reconstruction (Burkhart 2000)
Open vs Arthroscopic Bankart Repairs?
scopes have slightly better post op ROM, slightly higher recurrence rates. Slightly lower return to sport and return to work rates
Recurrence rate for bankart repairs that have concomitant glenoid defects?
at least 60% with glenoid defects of 20-30%
What is Remplissage procedure?
advancement of the infraspinatus into the engaging Hill-Sachs defect.
- for >25% humeral head deficiency
IF shoulder has crepitus in the 90/90 position, think
engaging Hill-Sachs lesion
Anatomic structures involved in Bankart tear:
- anteroinferior glenoid labrum
- MGHL
- IGHL
Anatomic area affected by Hill-Sachs lesion?
Posterosuperior humeral head
In a HAGL lesion, what is torn?
the anterior band of the IGHL
Pec transfer for subscap deficiency - results?
better for anterior instability than for arthroplasty
Best xray for viewing a Hill-Sachs
Stryker Notch View
- arm flexed up, hand resting on head
- A-P xray with 10 deg cephalad angulation
SH-III proximal humerus fractures in the adolescent: known copmlication?
AVN
- with observation they tend to revascularize and do well without long-term issues
(JDZ 1997)
Anterior Labroligamentous Periosteal Sleeve Avulsion Injuries: Treatment
the “ALPSA” lesion
- needs periosteal mobilization and fixation to the anterior glenoid neck in order to obtain glenohumeral stability
How do you treat a HAGL lesion?
Open capsular repair.
No scope!
