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4. OrthoBullets Questions > Shoulder & Elbow > Flashcards

Shoulder & Elbow Flashcards

1
Q

How many degrees do you aim to make the glenoid after TSA?

A

neutral

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2
Q

In valgus extension overload, when does pain occur (throwing phase)

A

Deceleration phase

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3
Q

Outcomes of ORIF vs. TEA in displaced intra-aritcular distal humerus fracture in elderly:

A

TEA has:

  • Better 1-2 year outcomes with TEA
  • less OR time with TEA
  • No difference in ROM
  • No difference in re-operation rates

McKee - JSES 2009

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4
Q

Humeral Head Cysts are associated with what kind of soft tissue pathology?

A

Chronic Rotator Cuff Tear

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5
Q

1st & 2nd line treatments in congenital radial head dislocation

A

1st: nonoperative
2nd: radial head resection

  • Do this as an adult if the patient is symptomatic
  • May show some improvement in pain and increased ROM
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6
Q

What type of constraint does a reverse total shoulder arthroplasty have?

A

Semi-constrained

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7
Q

AC separation classification

A

I: sprain

II: 25-100% displacement

III: >100% displacement

IV: Posterior

V: >300% through trapezius

VI: Subcoracoid

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8
Q

what are the 3 mechanisms of elbow dislocation?

A

Axial load: transolecranon dislocation

valgus posterolateral injury (most common)

varus posteromedial injury (coronoid fracture, tear of LCL)

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9
Q

What is the most important structue preventing medial subluxation of the LH biceps?

A

Subscapularis

Even a partial tear can lead to medial subluxation of the LHB

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10
Q

6 containdications for shoulder arthrodesis

A

Paralysis of the scapular muscles

Charcot arthropathy

Contralateral shoulder arthrodesis

Ipsilateral elbow arthrodesis

Elderly patient

Progressive neurologic disease

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11
Q

8 indications for shoulder fusion

A

Post-traumatic brachial plexus injury

Stabilization of paralytic disorder (in infancy)

Insufficiency of deltoid and rotator cuff with arthropathy

Chronic infection

Failed revision arthroplasty

Severe, refractory instability

Bone deficiency following resection of a tumour

Young, manual labourer, with triad of:

  • Massive rotator cuff deficiency
  • Deltoid muscle insufficiency
  • Excessive excision of acromion
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12
Q

Describe the insertion of the biceps on the radial tuberosity. What does each head do?

A

Long head inserts proximally

Short head inserts distally

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13
Q

Intra-operative options for irreparable rotator cuff tears:

A

tenolysis to mobilize

graft jacket

partial repair

move footprint

Bail and do tendon transfer

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14
Q

Greatest risk of failure of rotator cuff repair?

A

Age >65

NOT smoking

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15
Q

How do you get more ER in reverse TSA?

A

Reduce and get GT to heal

Concurrent tendon transfers (Lat dorsi)

ER osteotomy

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16
Q

Where does a reverse TSA move the center of rotation?

A

Medial & inferior

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17
Q

Cause of lateral epicondylitis:

A

Repeated microtraumatic tearing of ECRB

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18
Q

Best repair for coronoid fractures associated with terrible triad

A

Suture lasso technique

Better than plates/screws

Better than suture anchors

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19
Q

Where does the LUCL usually avulse off of?

A

Humeral attachment

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20
Q

2 ways to judge reconstruction of humeral head height

A
  1. 56mm higher than top of pec major insertion
  2. 7-8mm higher than GT
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21
Q

What is the most common location for suprascapular nerve impingement?

A

Suprascapular notch

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22
Q

Most common complications in distal biceps tendon repair/reconstruction?

A

Lateral antebrachial cutaneous nerve injury

  • Most common in both
  • new data suggests RARE in 2 incision (0-2%)
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23
Q

Interval for distal biceps tendon repair/

A

Radial: brachioradialis

Median: pronator teres

(used in both single and 2 incision techniques)

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24
Q

General options for correcting unstable TSA (reverse & anatomic)

A

Implant:

  • Head size: make sure not over-stuffed
  • lateralization of implant (more in reverse)

Bony:

Version:

  • Make sure it’s correct
  • If posterior instability (ie posterior dislocation), dial in more ANTEVERSION

Soft tissue repair:

  • Subscap repair (and ensure good force coupling)
  • capsule - ± plication
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25
Q

Name 4 contraindications to TSA as per AAOS clinical practice guidelines:

A
  • contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid)
  • rotator cuff arthropathy
  • irreparable cuff tears
  • deltoid dysfunction
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26
Q

3 complications UNIQUE to reverse total shoulder arthroplasty

A

Scapular notching

Acromial stress fracture

Dissociation of the glenoid component (glenosphere from head)

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27
Q

What is the most common complication of TSA?

A

Axillary nerve injury

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28
Q

What direction of displacement of a GT fracture causes the most biomechanical dysfunction?

A

Posterior

as per Rouleau JAAOS 2016

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29
Q

What has the strongest biomechanical fixation in distal biceps tendon repair?

A

Endobutton

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30
Q

Final outcome of adhesive capsulitis?

A

Decreased ROM compared to contralateral shoulder

It will NOT return to normal

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31
Q

Classification & treatment of acromial stress fracture

A

Classification by location:

  • I: lateral edge
  • II: AC joint
  • III: Medial to AC Joint

Treatment:

Type I:

  • excise

Type II:

  • Stable: AC joint resection
  • Unstable: distal clavicle excision and fix

Type III:

  • Asymptomatic: observe
  • Symptomatic: ORIF

*Generally, if Asymptomatic, leave them

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32
Q

How do you classify calcific tendinitis?

A

Precalcific

Calcific

  • Divided into formative, resting, resorptive

Post-calcific

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33
Q

What is a distinctive feature of OA of the elbow?

A

Maintenance of joint space

However ou do get hypertrophic osteophytes

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34
Q

Describe the Rockwood classification for AC joint separation

A

Type 1: AC ligament sprain - no displacement

Type 2: AC lig torn, CC lig sprain - displaced <25% CC distance

Type 3: CC distance of 25-100%

Type 4: Displaced posterior through trapezius (Axillary view)

Type 5: CC distance >100% (through deltotrapezial fascia)

Type 6: subacromial or subcoracoid

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35
Q

How do you size the radial head (3 ways)

A

Size the excised radial head in the measuring device from the set

Align the most proximal portion of the lesser sigmoid notch with the proximal surface of the implant (JAAOS 2014)

  • Note that the radial head actually sits 1mm proximal to the coronoid, but they suggest placing the implant at the level of the coronoid to avoid overstuffing

X-ray: medial and lateral joint lines are congruent

Check ROM - too big = abutment of radial fossa of humerus in flexion

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36
Q

4 complications unique to TEA

A

Bushing wear

Triceps avulsion

ulnar neuropathy

instability (collaterals)

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37
Q

You do a rTSA and need more ER. What do you do?

A

Lat dorsi transfer

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38
Q

How do you do a load and shift test?

A

Supine on table.

Bring shoulder to edge of table.

Apply axial load to center humeral head.

Translate HH anterior and then posterior.

Grades:

  1. Translation to rim
  2. dislocation with spontaneous relocation
  3. dislocation without relocation
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39
Q

Outcomes of 1 incision vs. 2 incisions in distal biceps repair:

A

2 incisions:

greater final flexion strength

less incidence of LABC nerve injury

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40
Q

Treatment/surgical options

A

Nonoperative if functional.

Operate if non-functional

If unilateral, set in supination of 10-20 degrees

If bilateral:

Fix dominant arm in pronation (30-45 degrees)

Fix non-dominant arm in supination (20-35 degrees)

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41
Q

Describe the order of soft tissue disruption in an elbow dislocation

A

Hori Circle

LCL first

then Anterior/posterior capsule

Then MCL

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42
Q

List 5 options to surgically treat a stiff elbow

A

osteophyte excision & debridement

distraction interpositional arthroplasty

total elbow arthroplasty

capsular release +/- release of posterior band of MCL indications

musculocutaneous neurectomyindications

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43
Q

Describe Oberlin transfer

A

Ulnar nerve to upper trunk for upper trunk brachial plexus injury

ie ulnar to musculocutaneous

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44
Q

What has more predictable results in treatment of proximal humerus fractures in the elderly?

A

Reverse shoulder arthroplasty

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45
Q

2 things that increase MCL (elbow) stress

A

Increased glenohumeral IR torque

Poor throwing mechanics

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46
Q

Isolated supraspinatus tear: can you do a TSA?

A

Yes

An isolated supraspinatus tear with no retraction is NOT A CONTRAINDICATION to TSA

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47
Q

10 year revsion free survivorship for TEA in RA?

A

92%

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48
Q

5 Physical signs of rotator cuff arthropathy

A

+ ER lag sign

+ Hornblowers

Anterosuperior escape

Pseudoparalysis

Subcutaneous effusion (from loss of containment of capsule and bursa) - there is a name for this sign but I can’t find it - Geissler’s?

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49
Q

What percentage of patients >60 have a rotator cuff tear on imaging?

A

35-55%

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50
Q

68 year old patient with OA of shoulder and intact rotator cuff. What will give this patient most reliable pain relief?

A

TSA

TSA > HA in providing predictable pain relief

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51
Q

X-ray for AC joint separation

A

Zanca

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52
Q

What is the effect of subacromial decompression on rotator cuff repair?

A

None - results equivocal

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53
Q

What is normal glenoid version?

A

+5 to -12 degrees of retroversion

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54
Q

Causes of Elbow Contracture? (7)

A

rauma

surgery

arthritis

cerebral palsy

traumatic brain injury

burns

congenital conditions:

  • arthrogryposis
  • congenital radial head dislocation
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55
Q

How do you avoid scapular notching in rTSA?

A

inferior position & inferior tilt of glenosphere

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56
Q

List 5 ways to deal with posterior glenoid bone loss in an arthritic shoulder

A

Eccentric Reaming

Autograft (humeral head)

Augment (porous metal)

Hemiarthroplasty

Reverse total shoulder Arthroplasty

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57
Q

Which nerve is at risk with an inferior capsular shift (arthroscopic) and how far away from capsule is it at 6 oclock?

A

Axillary nerve branch to teres minor

12 mm

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58
Q

When do the superior, middle and inferior glenohumeral ligaments provide stability (what angle)?

A

SGHL: adduction

MGHL: 45 degrees abduction

IGHL: 90 degrees abduction

Think of this when they ask about structures torn in shoulder dislocations

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59
Q

2 absolute and 3 relative contraindications to TEA?

A

Absolute:

  • Active infection (arthrodesis favoured)
  • Charcot joint

Relative:

  • Poor neurologic control of affected extremity
  • Active patient <65 years
  • Olecranon osteotomy
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60
Q

Contraindications (4) of rTSA

A

Deltoid deficiency (axillary nerve palsy)

Bony acromion deficiency

Glenoid osteoporosis

Active infection

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61
Q

After anatomic TSA, how far above the GT should the humeral head be?

A

5-8mm

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62
Q

Tendon transfer for irreparable subscap tear?

A

Pec Major transfer

  • Pec Major transferred to LT or anteromedial GT
  • Must have intact infraspinatus
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63
Q

How do you maximize sensitivity in intraop assessing for infection?

A

5 cultures at least

Take cultures from seprate regions of both soft tissue and bone

Hold cultures for at least 2 weeks: p.acnes is slow growing

Ultrasound of the implants (to shake off the glycocalyx so that they can culture it)

*No good evidence for intraoperative frozen section (in shoulders)

* If suspecting infection, new data says arthroscopic bx better than aspiration

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64
Q

Outcomes of revision SLAP repair?

A

Worse than those of primary surgery

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65
Q

New classifiation system of GT fractures

A

Avulsion: fracture line perpendicular to humeral shaft

Depressed

Split: fracture line parallel to humeral shaft

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66
Q

Why is the anteromedial facet prone to injury in a varus posteromedial instability situation?

A

It gets sheared off by the trochlea

60% of it is unsupported by the ulnar shaft, making it more prone to injury

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67
Q

Indications for operative management of Hill-Sachs

A

Classic: >30-40% defect

New: Off-track lesion (engaging) no matter the size

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68
Q

Complications of nonop management of radial head fractures

A

Elbow stiffness

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69
Q

Insertion of MCL (elbow)

A

Sublime tubercle of ulnar

In proximity to coronoid

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70
Q

3 options for fixation in distal biceps tendon repair

A

All suture method

interference screw

endobutton

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71
Q

What open approach do you use for a posterior shoulder dislocation?

A

Deltopec (go from the front)

But Rouleau says anterior or posterior (JAAOS 2014)

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72
Q

Contraindications to TSA (6)

A
  • insufficient glenoid bone stock
  • rotator cuff arthropathy
  • deltoid dysfunction
  • irreparable rotator cuff (hemiarthroplasty or reverse total shoulder are preferable as TSA causes risk of loosening of the glenoid prosthesis is high (“rocking horse” phenomenon)
  • active infection
  • brachial plexus palsy
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73
Q

Whatis Friedman’s line?

A

Line in the plane of the scapular on the axial CT view through the glenoid

Helps you judge version

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74
Q

Elbow pivot shift

How do you do it?

What does it indicate?

A

(± Arm brought over head so elbow looks like a knee)

Forearm is supinated and a valgus and axial load is applied

Elbow is then brought from full extension into flexion

+ dislocation/subluxation is postiive for PLRI

basically you’re just recreating the PLRI mechanism

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75
Q

What are the primary restraints to posterior humeral subluxation in:

IR

ER

adduction

A

IR: posteriro band of IGHL

ER: subscap

Adduction: SGHL

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76
Q

Most common nerve injury in shoulder dislocation?

A

Axillary

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77
Q

What is the main blood supply to the humeral head?

A

Posterior humeral circumflex artery

Used to be anterior - new data shows posterior

78
Q

Rehab protocol for TEA for RA? OA?

A

OA: early ROM at 2 weeks

RA: cast immobilization for 4 weeks, then start ROM

  • Delayed ROM protects against wound problems, early loosening, instability (vs early ROM )
79
Q

Too lateral reduciton/placement of the LT in shoulder arthroplasty will result in a deficit of what motion?

A

ER

b/c too much tension

80
Q

Pathophysiology of LIttle Leaguer’s Elbow?

A

Repetitive contraction of flexor-pronator mass resutling in apophysitis

81
Q

Name 5 complications with distal biceps tendon repair?

A

LABC nerve injury (most common)

Radial nerve injury (most severe)

Synostosis

HO

Rerupture

Decreased final strength in flexion/supination

82
Q

Risk factors for failure of reverse/anatomic TSA

A

Obesity: they will be in abducted, ER position due to body habitus

Mobility aids: increase shear force through implant

83
Q

Geyser Sign

A

Passage of fluid from the glenohumeral joint into the acromioclavicular joint on arthrography is referred to as the geyser sign. It can be seen with chronic rotator cuff tendon tear or after injury of the acromial undersurface during surgery.

84
Q

What ligament do you release in surgical release of stiff elbow to gain flexion?

A

Posterior band of MCL

85
Q

Stages of Frozen Shoulder

A

1: freezing:

  • inflammation & pain
  • Lasts 3-9 months

2: Frozen

  • profound capsular stiffness & limited ROM
  • Lasts 3-12 months

3: Thawing:

  • Gradual, spontaneous improvement in shoulder motion and function
  • Lasts 1-3 years
86
Q

Best places for fixation on glenoid side in arthroplasty (doesn’t matter what kind of arthroplasty)

A

Lateral border of scapula (inferiorly): most important

Base of Coracoid

Center of Glenoid

87
Q

What is a positive Gagey?

A

Passive abduction greater than 105 degrees.

Indicates inferior laxity.

88
Q

Indications for fixation of GT fracture?

A

5mm displaced

argument for 3mm displaced in a young, healthy overhead worker

(Rouleau JAAOS 2016)

89
Q

Classification of SLAP tears

A

I: labral fraying

II: biceps tear

III: Bucket handle

IV: bucket handle with biceps torn off

90
Q

What phase of throwing is the rotator cuff most susceptible to tension failure? Why?

A

Deceleration phase

It is the main decelerator of the shoulder and undergoes most eccentric tension during this phase

91
Q

What is the loss of elbow flexion and supination strength in a proximal biceps rupture

What happens in repair?

A

Flexion: negligible

Supination: 10-20%

No significant difference with repair

92
Q

Risks of failure in bankart repair:

A

Age

Contact Sports

Glenoid bone loss (bony bankart)

Hill Sachs lesion

93
Q

Describe the instability severity index score (ISIS)

A

Determines appropriateness of soft-tissue arthroscopic vs. bony repair open in shoulder instability

Age at surgery

>20: 0

Degree of participation in sports (pre-op)

Competitive: 2

Recreational or non: 0

Type of sport (pre-operative)

Contact or forced overhead: 1

Other: 0

Shoulder Hyperlaxity:

Hyperlax either ER >85 with arm at side or + Gagey: 1

Normal: 0

Hill Sachs on AP:

Visible on ER: 2

Not visible on ER: 0

Glenoid loss of contour on AP

Loss of contour: 2

No lesion: 0

Total = 10

= 6: acceptable recurrence risk of 10% with arthroscopic stabilization

>6: unacceptable recurrence risk of 70% and should undergo open surgery (Latarjet)

94
Q

What is the primary stabilizer of valgus stress to the elbow

A

Anterior band of the anterior bundle of the MCL

95
Q

Complications from surgical fixation of radial head

A

Pain

Instability (PLRI)

Proximal radial migration

Decreased strength (including grip)

Cubitus valgus

HO

Post-traumatic OA of the trochlea-olecr

96
Q

7 Risk factors for GH dislocation post rTSA

A
  • Irreparable subscapularis (strongest risk factor)
  • Proximal humeral bone loss
  • Previous failed arthroplasty
  • Proximal humeral nonunion
  • Fixed GH dislocation preop
  • Massive rotator cuff tears with pseudoparalysis
  • Excessive humeral retroversion >10 degrees

*note: inflammatory arthritis is NOT a risk factor*

97
Q

Complications of shoulder hemiarthropalsty (5)

A

Progressive glenoid arthrosisRisk:

Tuberosity displacement/malunion

Repositioning of tuberosity with bone grafting

Joint overstuffing

Sucutaneous (anterosuperior) escape

98
Q

Normal acromiohumeral interval (AHI)

A

8-12mm

99
Q

Name 2 types of shoulder hemiarthroplasties in terms of head shape:

A

Standard humeral head

Extended coverage humeral head

  • used for rotator cuff arthropathy: the head sits in the acetabularized acromion
100
Q

How much correction can you safely achieve with eccentric reaming of a retroverted glenoid in TSA?

A

Up to 15 degrees

101
Q

Patient >40 years old, post-shoulder dislocation, cannot raise arm? Best test? What are you looking for?

A

MRI shoulder

For ?massive rotator cuff tear

patients >40 with shoulder dislocation have 35-85% rate of massive rotator cuff tear

102
Q

In unconstrained TSA for proximal humerus malunion, what concomitant procedure provides worse outcomes?

A

Tuberosity osteotomy (ie for malunited tuberosities)

OK to insert the humeral stem eccentrically/nonanatomically

103
Q

What are the risks and benefits of lateral decubitus vs. beach chair position in shoulder arthroscopy?

A
104
Q

List 7 factors that predict failure of operative Rotator Cuff Repair

A

Age (>60-70)

Retraction

Muscle atrophy (Tangent sign)

Fatty Infiltration (Goutallier)

Tear Size

Smoker

Diabetic

105
Q

Name the classification systems (x2) for elbow RA. Describe both

A

Larsen & Mayo

Larsen:

Stage I: soft tissue involvement, normal xrays

Stage II: periarticular erosions & mild cartilage loss ± osteopenia

Stage III: marked joint space narrowing

Stage IV: progressed erosions past subchondral plate

Stage V: Loss of joint space contour

Mayo:

I: Soft tissue swelling and periarticular osteopenia. Generally normal x-rays

II: Mild to moderate joint space narrowing. Synovitis recalcitrant to NSAIDs

III: Thinning of the joint space contours

IV: Extensive articular damage

106
Q

Should you do routine acromioplasty in RTC repair?

A

No - routine acromioplasty non-requied

moderate evidence

AAOS CPG 2010

107
Q

What treatment is contraindicated in cuff tear arthropathy?

A

Anatomic total shoulder arthroplasty

108
Q

Plan for infected TSA 4 weeks out?

A

Open I&D

May retain implants when acute (

However staged revision is always a safe answer

109
Q

4 signs of a posterior shoulder dislocation in brachial plexus injury

A
  • asymmetry of skin folds of the axilla or the proximal aspect of the arm (anterior shoulder crease)
  • apparent shortening of the humeral segment
  • a palpable asymmetric fullness in the posterior region of the shoulder
  • a palpable click during shoulder manipulation

(doesn’t include decreased ER bc that is also a sign of the brachial plexus injury)

110
Q

Treatment for staph epidermidis or p.acnes infection in TEA?

A

2 stage revision

Will lead to persistent infection if no explant and recurrence if 1 stage revision

111
Q

In partial distal biceps tear, where is the tear located?

A

Radially - it peels off

112
Q

What is a terrible triad injury of the elbow?

A

Elbow dislocation

coronoid fracture

radial head fracture

(DOES NOT include LCL injury)

113
Q

Average medial to lateral distance of supraspinatus footprint on GT?

A

14-16mm

114
Q

Essential lesion for PosteroMEDIAL rotatory instability

A

LUCL rupture

anteromedial coronoid fracture

(NO radial head fracture - distinguishes it from PLRI)

115
Q

Position of Shoulder Arthrodesis

A

30/30/30

(flex/abd/IR)

116
Q

Most common site of PIN compression

A

Fibrous bands of supinator (distal edge)

117
Q

What must you check for in a patient suspected of medial epicondylitis?

A

Ulnar neuritis (40%)

MCL injury

118
Q

First line managmenet for post-traumatic elbow stiffness?

A

Progressive static splinting

119
Q

Conceptually, how does a reverse shoulder arthroplasty work?

A

Provides a fulcrum for the deltoid to work

120
Q

4 releases with subscap release (open)

A

(1) its superior margin from the coracoid
(2) the posterior surface from the anterior capsule and scapular neck
(3) the inferior border from the axillary nerve and circumflex vessels
(4) the anterior surface from the conjoined tendon.

121
Q

What is the majority of motion GAINED from rTSA? Lost?

A

Gained: forward flexion

Lost: ER/IR

122
Q

Plan for infected TSA 3 months out?

A

Explant + staged revision + abx

± one stage

Must explant if chronic infection >6 weeks

123
Q

7 radiographic findings in rotator cuff arthropathy

A

acromial acetabularization (true AP)

femoralization of humeral head (true AP)

asymmetric superior glenoid wear

lack of osteophytes

osteopenia

“snowcap sign” due to subchondral sclerosis

anterosuperior escape

124
Q

2 reductio maneuvers for luxatio erecta

A

Traction - counter traction

2 step

  • Convert to anterior-inferior dislocation by pulling laterally
  • Then do regular reduction
125
Q

What is the initial treatment for a symptomatic patient with a partial RTC tear?

A

exercise and NSAIDs

AAOS CPG 2010

126
Q

What is the primary stabilizer against varus stress of the elbow?

A

Lateral ulnar collateral ligament

127
Q

Pseudoparalysis is a sign of what shoulder pathology?

A

Cuff tear arthropathy

128
Q

Most common mechanism for posterior shoulder dislocation?

A

Flexion, adduction, IR

Therefore SGHL is most important stabilizer in this position

(Rouleau JAAOS 2014)

129
Q

Name 3 primary and 3 secondary static stabilizer of the elbow

A

Primary:

  • Ulnohumeral articulation (coronoid)
  • LCL
  • MCL (anterior band)

Secodary:

  • radiocapitellar joint
  • capsule
  • common extensor and flexor origins
130
Q

Findings in Panner’s disease (OCD elbow)

A

Fragmentation of the capitellum

enlargement of radial head

Premature distal humeral physeal arrest

degenerative changes leading to incongrity between radiocapitellar joint

131
Q

Rate of rotator cuff tear post shoulder dislocation age >40? >70?

A

Age >40: 55%

Age >70: 100%

Check for this - it’s NOT an axillary nerve injury

132
Q

Name 5 things that decrease MCL strain (elbow)

A

Decreased throwing velocity

Trunk-scapular kinesis

Scapular protraction/retraction

Forearm pronation

Dynamic flexor-pronator stabilization/contraction

133
Q

Which part of the MCL (elbow) is tight in flexion?

A

posterior bundle

PAL: same as in ACL

134
Q

2 surgical approaches for distal biceps rupture. What is gold standard?

A

1 incision

2 incision - considered gold standard now

135
Q

Name 3 arthroscopic techniques to help repair large rotator cuff tears:

A

Margin convergence

Anterior interval slide

Posterior interval slide

136
Q

Complication rate for TEA done for RA?

A

High: 14% overall

Higher with OA: 25-43%

137
Q

What soft tissue structure can be injured in valgus extension overload?

A

MCL of elbow

138
Q

Main primary restraint to posteiror shoulder dislocation:

Flexion, adduction, IR

Abduction, IR

Abducted, ER

A

Flexion, ADDudction, IR:

  • SGHL, CHL

Abduction, IR:

  • posterior band of IGHL

Abducted, ER:

  • subscap
139
Q

What phase of throwing exerts the most stress on the MCL (elbow)

A

late cocking/early acceleration

140
Q

How do you perform a reduction of a posterior shoulder dislocation?

A

Traction (Stimson method)

or

Manipulation: (see below)

(JAAOS 2014)

Two operators are needed for the reduction maneuver.

The physician forward flexes the shoulder to 90° then adducts and internally rotates the arm to disengage the humeral head from the glenoid rim.

The assistant maintains cross-body traction while the physician applies gentle, anteriorly directed pressure to the posterior humeral head.

Finally, external rotation can be attempted to complete and confirm reduction

141
Q

Greatest direction of loss of ROM in frozen shoulder?

A

ER

essential lesion in adhesiv capsulitis involves CH ligament/rotator interval

142
Q

Valgus elbow instability is indicative of what type of instability pattern?

A

Valgus posterolateral instability

Suggests rupture of LUCL for sure (±MCL)

(JAAOS 2015)

143
Q

Initial Managemnet of adhesive capsulitis?

A

gentle, painfree stretching (doesn’t need to be aggressive)

144
Q

Microscopic evaluation of lateral epicondylitis shows what?

A

Angiofibroblastic hyperplasia

disorganized collagen

145
Q

For glenoid component in anatomic total shoulder arthroplasty, is peg or keel biomechanically superior?

A

Peg

146
Q

List 6 predictors of successful non-operative Rotator Cuff Tear management

A

Female

Good scapulothoracic motion

Older age >65

Low demand

Higher baseline QOL scale

Realistic patient expectations

147
Q

Medial to lateral footprint size of the supraspinatus footprint?

A

11-14mm

148
Q

You want to relocate a dislocated shoulder, what kind of anesthesia do you use?

A

Intra-articular block with lidocaine

Intra-arrticular block should be first, with conscious sedation reserved for difficult reductions

Intra-articular block shows:

  • same degree of analgesia
  • Same success rate
  • Lower cost
  • lower time in ER
  • Lower overall complications

JAAOS 2014

149
Q

Outcomes of TSA:

10 year survival

Pain vs. Hemi

ROM

A
  • pain relief most predictive benefit (more predictable than hemiarthroplasty)
  • reliable range of motion
  • good survival at 10 years (93%)
  • good longevity with cemented and press-fit humeral components
  • worse results for post-capsulorrhaphy arthropathy
150
Q

Outcomes post arthroscopic RTCR of 6 weeks immobilization vs. early ROM?

A

equivalent

151
Q

Prior to reverse TSA, you want an MRI, why? 2 reasons:

A

Intergrity of rotator cuff

Fatty infiltration of the muscles (including deltoid)

152
Q

What 2 ligaments mark the superior border of the subscap?

A

Coracohumeral ligament

superior glenohumeral ligament

153
Q

GT displacement/malunion in what position has a poor prognosis, independent of amount of displacement?

A

posterior

154
Q

Most common nerve complication after distal biceps tendon repair?

A

Lateral antebrachial cutaneous nerve (for both approaches)

radial is most severe

155
Q

Where is the center of rotation moved in a reverse TSA?

A

medial and inferior

156
Q

Major radiographic finding of inflammatory arthritis of elbow (x2)

A

Erosive arthritis with significant bone loss

Loss of joint line

157
Q

Major sequelae of hypotensive episodes in semi-upright shoulder arthroscopy?

A

Asystole

ishaemic brain injury

ischaemic spinal cord injury

158
Q

Name 5 shoulder reduction techniques

What’s the best?

A

Hippocratic

  • Pull & adduct arm with foot in armpit

Kocher’s

  • Arm at side, 90 @ elbow, pull and ER –> IR

Milch

Stimson

  • Hang arm with weights while prone

Matsen Traction-Counter traction

  • With a sheet

Eskimo

Scapular Manipulation

FARES: (Fast, Reliable & Safe)

Adduction with elbow extended. Short vertical oscillating movement and bring arm to abdcution and ER. Should reduce around 120 abduction

159
Q

3 options for rotator cuff arthropathy

A

Non-operative management

Reverse total shoulder arthroplasty

Extended surface head hemiarthroplasty

160
Q

4 risk factors or poor outcome following lat dorsi transfer for irreparable posterosuperior RTCT?

A

Nonsynergistic action of the transferred muscle

Fatty atrophy of the supra/infraspinatus muscles

Deficieincy of Subscap

Deltoid weakness

161
Q

Name 4 indicators of an irreparable rotator cuff tear

A

1) Superior displacement of the humeral head (AHI
2) Fatty infiltration of the rotator cuff muscles (Goutallier stage 3-4)
3) Increased duration of the tendon tear
4) Profound external rotation weakness.

Because they lead to poor prognoses post-op

162
Q

Name the signs of a preganglionic brachial plexus injury:

A

Root avulsion, so:

winged scapula (long thoracic nerve)

absent serratus anterior (long thoracic)

absent rhomboid (dorsal scapular nerve)

rotator cuff (suprascapular nerve)

latissimus dorsi (thoracodorsal nerve) function

Horner’s syndrome (sympathetic chain)

elevated hemidiaphragm (phrenic nerve).

163
Q

Posterior shoulder dislocation: what is the rate of concomitant surgical neck fracture?

A

50%

164
Q

How do you prevent cerebral hypoperfusion in shoulder arthroscopy/open procedures (especially with beach chair)

A

sBP >90mmHg

Max decrease of sBP & MAP

165
Q

Post shoulder reduction rehab program (1st time dislocation - traumatic)

A

Immobilize minimum 3-4 weeks

Anterior: no ER past neutral

Posterior: No IR past neutral

166
Q

What is the most common cause of TSA failure?

A

glenoid component loosening

167
Q

Name 2 ways of judging version in shoulder reconstruction

A
  1. Transepicondylar axis
  2. Pre-op planning
  3. Jig
168
Q

5 signs that radial head dislocation is congenital

A

Bilateral

non-traumatic

posteriorly dislocated

convex radial head

hypoplastic capitellum

Associated with other congenital anomalies (achondroplasia)

Difficult to reduce

associated with bowing and shortening of the radius

may be asymptomatic

169
Q

Patient with Post op shoulder surgery pain. He had an intra-articular local anesthetic pump. Dx?

A

Chondrolysis secondary to local anesthetic infusion

170
Q

Risk factors for posterior shoulder dislocation:

A

Epilepsy

Excessive Glenoid retroversion

Excessive humeral retroversion

Reverse hill-sachs

171
Q

In valgus extensio overload, where are the osteophytes?

A

Posteromedial olecranon fossa

172
Q

2 techincal factors that place RTC tendons at risk during TSA arthroplasty

A

Too distal of a head cut

Head cut too retroverted

173
Q

5 risk factors for adhesive capsulitis (Frozen shoulder)

A

Diabetes

Thyroid disease (autoimmune etiology)

Previous surgery (lung/breast)

Prolonged immobilization

Extended hospital stay

174
Q

Indications for hemiarthroplasty (4)

A

Primary arthritis if:

  • Rotator cuff is deficient
  • Glenoid bone stock is inadequate
  • Risk of glenoid loosening is high (young, active, labourer)

Rotator cuff arthropathy

  • Hemiarthroplasty > rTSA if able to achieve forward flexion >90 degrees

Osteonecrosis without glenoid involvement

Proximal humerus fractures

175
Q

Cause of acromial stress fracture:

A

Overtension of the deltoid

176
Q

3 Radiographic signs of high-riding humerus (RTC arthropathy)

A

Decreased acromiohumeral interval (

Break in Shenton’s line

Acetabularization of the acromion

Also: Femoralization of the humeral component: rounding off of the GT

177
Q

What is the best surgial technique for MCL reconstruction of the elbow?

A

Humeral docking via flexor pronator split, no ulnar nerve transposition

better outcomes and complication rates

biomechanically stronger

95% strength of native ligament

178
Q

+ elbow varus stress test is indiative of what pathology?

A

posteroMEDIAL rotatory instability

179
Q

Treatment for shoulder tuberosity malunions greater than and less than 1.5cm

A

Less than 1.5cm: arthroscopic vs. open acromioplasty (to prevent impingement) and tuberoplasty

More than 1.5cm:

Large fragment: tuberosity osteotomy

Small fragment: tuberoplasty

JAAOS 2014

180
Q

T/F

Surgical resection/management of calcific tendinitis results in higher risk of rotator cuff tear?

A

False

very low rates of tendon injury/compromise post surgical resection

181
Q

What are ywo options when you have excessive glenoid retroversion in anatomic total shoulder arthroplasty?

A

Build up posterior glenoid via bone graft/augments

eccentrically ream the anterior glenoid (if there is enough bone stock anteriorly)

182
Q

Name 2 ways to get more ER with a reverse total shoulder arthroplasty:

A

Concomitant latissimus dorsi transfer

ER ostoetomy of the humerus

183
Q

7 indications for rTSA

A

Rotator cuff arthropasthy

Pseudoparalysis

Antero-superior escape

Acute 3-4 part PHF

Where GT has poor healing potential

RTC insufficiency equivalent

  • Nonunion or malunion of the tuberosity following trauma or prior arthroplasty

Failed arthroplasty

RA

  • If bone stock is sufficient
184
Q

Functional ROM of the elbow

A

30-130 extension/flexion

ie the range the MCL is most important

185
Q

Tendon transfer for irreparable supra and/or infraspinatus tear?

A

Lat dorsi transfer: for infraspinatus irreparable tear (ER lag)

Lat dorsi and/or teres major is transferred to GT

Must have intact subscap

186
Q

3 ways to help mobilize a retracted tendon while repairing RTC:

A

Maximum relaxation/paralysis

Change position of arm

Tenolysis - thorough superior, inferior, medial, lateral

187
Q

Incidence of the following in luxatio erecta:

cuff tears/GT fractures

Neurologic injury

vascular injury

A

cuff tears/GT fractures: 80%

Neurologic injury: 60%

vascular injury: 39%

188
Q

T/F

MGHL is absent in 60% of shoulders?

A

False

MGHL is absent in 30% of shoulder

189
Q

What are the essential lesions ofr varus posteromedial elbow instability?

What happens if it’s not diagnosed/treated early?

A

Coronoid fracture (anteromedial facet)

LUCL injury

Can lead to rapid onset of ulnohumeral arthritis

190
Q

IN Bilatera elbow fusion, what angles do you fuse at?

A

Dominant arm: >90 deg

Non-dominant arm:

4. OrthoBullets Questions (20 decks)

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