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Orthopaedic Surgery > Shoulder/Elbow > Flashcards

Shoulder/Elbow Flashcards

1
Q

What is an anterosuperior RC tear?

A

Tear extending from subscap to or through the supraspinatus tendon

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2
Q

How to release adherent subscap tendon for repair.

A

Anterior surface

Release from behind the tip of coracoid and coracoid neck. Release behind the conjoint tendon.

Superior margin

Released from coracoid (release CH ligament too, basically skeletonizing coracoid)

Inferior margin

Axillary nerve and artery coursing from A to P around 3-5mm medial to musculotendinous jxn.

Posterior surface

Released from anterior capsule and glenoid neck

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3
Q

Loss of labrum decreases translational resistance by what percentage?

A

20%

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4
Q

What prevents posterior displacement with shoulder in flexion, IR and ADDuction?

A

SGHL and CHL

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5
Q

Posterior band of IGHL limits posterior displacement in what arm position?

A

Shoulder abduction

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6
Q

SGHL/CHL function?

A

Resist inferior translation and ER with arm adducted at the side, in neutral rotation.

Also limits posterior translation with arm flexed, IR and adducted

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7
Q

MGHL function?

A

Limits anterior translation with arm abducted to 45 degrees

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8
Q

Contents of rotator interval?

A

CH, SGHL, long head biceps

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9
Q

Primary restraint to anterior translation with abducted arm

A

Anterior band of IGHL

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10
Q

Most common associated fracture with a posterior shoulder dislocation?

A

Humeral neck (55%)

Then LT (42%)

then GT (23%)

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11
Q

Prevalence of reverse hill sachs and reverse bony bankart in posterior shoulder dislocation?

A

29% reverse hill sachs

5% reverse bony bankart

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12
Q

Algorithm for addressing reverse Hill sachs lesions

A

<20%

  1. Scope or open reverse Bankart repair
  2. McLaughlin Procedure

(peel and transfer SS into defect, or just anchor and suture SS into defect in situ)

**Must leave inferior rim of SS anatomic to preserve circumflex vessels!**

20-40%

Modified McLaughlin (LT osteotomy and transfer into defect)

Elevation of impaction, bonegraft

>40%

Arthroplasty or Allograft

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13
Q

Axillary nerve - how far from glenoid?

Which shoulder position maximizes the distance?

A

Mean of 12.4 mm from 6 o’clock glenoid

Abduction, ER and traction.

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14
Q

Nerve supply to subscap

A

Upper and lower subscapular nerve

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15
Q

Nerve supply to teres major

A

Lower subscapular nerve

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16
Q

Nerve supply to latissimus dorsi

A

Thoracodorsal nerve

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17
Q

Nerve to pec minor

A

Medial pectoral nerve

(vs pec major which is medial and lateral)

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18
Q

Location of thoracic outlet and other locations of compression

A

Between anterior and middle scalenes

Sites of compression
Abnormal scalene anatomy

Large transverse process

Cervical rib

Scapular ptosis

Clavicle or 1st rib malunion

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19
Q

Complications of TSA in order:

A

component loosening

instability

periprosthetic fracture

rotator cuff tears

neural injury

infection

deltoid muscle dysfunction

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20
Q

Elbow arthroscopy portals (7)

List nerves at risk for each

A
  1. Anterolateral (just anterior to RC joint) RADIAL and LABCN
  2. Anteromedial (1-2cm anterior and distal to medial epicondyle) MABC and MEDIAN
  3. Proximal anteromedial/anterolateral portals (each 2cm prox to epicondyle and just anterior to supracondylar ridge) AM: MEDIAN&ULNAR AL: RADIAL
  4. Direct lateral (soft spot)
  5. Distal ulnar (3-4cm distal to RC joint along lateral border of ulna)
  6. Direct posterior (3-4cm prox to tip of olecranon) PABCN&ULNAR
  7. Posterolateral (level of tip of olecranon, lateral side) PABCN
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21
Q

Insertion of biceps on bicipital tuberosity?

A

Long head proximal and short head distal.

Both ulnar.

22
Q

Distal biceps tendon repair:
1 vs 2 incision technique

A

Equal function at 2 years

2 incision technique - 10% more flexion strength

LABCN injury: 40% in 1 incision, 7% in 2 incision group

Equal HO rate

23
Q

Counsel re: nonop distal biceps treatment

A

Will lose 50% supination strength

Will lose 30% flexion strength

Will lose 15% grip strength

24
Q

More common: proximal or distal biceps tendon rupture?

A

Proximal!

25
Q

Four special test for medial elbow

A

Valgus stress test at 30degrees

Milking maneuver

Moving valgus stress test (pain b/w 120 and 70)

Valgus extension overload test (snap elbow into extension with valgus stress on it)

26
Q

Most throwing MCL injuries in baseball occur during which phases of throwing?

A

Late cocking/early acceleration

27
Q

Difference in mode of failure of LUCL vs MCL in terrible triad injuries

A

LUCL almost always avulsed off lateral epicondyle

MCL can be avulsed off either origin or insertion, or midsubstance tear.

28
Q

Test for elbow stability after terrible triad fixation?

A

Hanging Arm Test

Elbow in extension and full supination against gravity. Fluoro AP and lateral must show congruent joint. If not, fix MCL and/or exfix

29
Q

How much of the anteromedial coronoid facet is supported by ulnar metaphysis?

A

40% supported

60% unsupported

30
Q

O’Driscoll classification of coronoid fractures

A
  1. Tip
  2. i. Anteromedial rim
    2ii. Rim and tip
    2iii. Rim and sublime tubercle
  3. Base
31
Q

Postop immobilization position after repair of valgus posterolateral instability and varus posteromedial instability

A

Valgus posterolateral: in pronation (neutral if MCL repair done)

Varus posteromedial: in neutral

32
Q

Best xray to assess acromion profile

A

Supraspinatus outlet view

33
Q

Phases of calcific tendonitis?

A

Type 1 (painful) fluffy appearance, “resorptive” phase

Type 2 (non painful) well defined calcification. “Formative” phase

34
Q

Goutallier classification

A

0 normal

1 fatty streaking

2 more muscle than fat

3 muscle = fat

4 more fat than muscle

35
Q

What is the “comma sign” and what does it signify?

A

Arc formed by SGHL/CHL complex.

Tip of comma at the superolateral aspect of the avulsed subscapularis tendon

36
Q

Surgical indications for partial thickness RC tears

A

Failure of nonop mgmt

Bursal sided tear >25% (or 3mm thickness)

Articular sided tear >50% (or 6mm thickness)

37
Q

What is a Bennett lesion?

A

Exostosis of posterior glenoid rim.

Associated with internal impingment:

Posterior capsular tightness leading to posterosuperior shift of humeral head. During ER and abduction (throwing) can have peelback of superior labrum, articular sided posterior cuff fraying, cartilage damage of posterior glenoid, and Bennett lesion.

38
Q

Seebauer classification of RC arthropathy

A

1: No proximal migration (centred)

A:Stable

B:Medialized

2: Proximal migration

A:Limited stability

B: Anterosuperior escape

39
Q

Three factors to help guide surgical tx of RC arthropathy.

A

Age?

Young: Hemi

Old: RTSA

Can they elevate?

Yes: Hemi

No (pseudoparalysis): RTSA

Anterosuperior escape?

Yes: RTSA

No: Hemi

40
Q

What is a West Point axillary view?

What does it show?

A

Prone, shoulder abducted to 90 with elbow flexed.

Beam 25 off midline and 25 above horizon

Shows glenoid bone loss

41
Q

What is a Stryker Notch view?

What does it show?

A

Supine with hand on head. Beam angled 10 cephalad

Shows Hill Sachs lesions

42
Q

In MDI surgery after capsular shift, what is risk of closing the rotator interval?

A

Risk losing ER range of motion

43
Q

Classify SLAP lesions!

A

1: Labral fraying, biceps anchor intact (debride)
2: Labral detachment, biceps detached (reattach)
3: Bucket with intact biceps (debride bucket)
4: Bucket with detached biceps (debride bucket, tenodese/tenotomy)
5: SLAP with anterior labrum (repair)
6: Superior flap tear aka parrot beak (repair or debride)
7: SLAP w/ capsular injury (repair)

44
Q

Describe a Buford complex.

A

Labral anatomic variant with absent anterosuperior labrum, instead there originates a cord-like MGHL

45
Q

Describe a sublabral foramen

A

Labral anatomic variant where the labral is not attached anterosuperiorly. (often mistaken for a SLAP tear)

Can be differentiated from SLAP tear because slap tears will usually continue posteriorly to involve the biceps anchor.

46
Q

Name 2 types of scapular winging and their operative treatment of choice.

A

Medial winging

from loss of serratus function (Long thoracic nerve)

Treat with Pec major transfer to inferior angle of scapula)

Lateral winging

from loss of traps (spinal accessory nerve)

“Eden Lange” transfer. Levator and rhomboid insertion on scapula osteotomized and transferred laterally.

47
Q

Position of hemiarthroplasty

A

GT should be 10mm inferior to top of prosthesis

Top of prosthesis should be 56mm superior to pec major insertion

Retrovert 20-30 degrees

48
Q

Contraindications to TSA (name 6)

A

Insufficient glenoid bone stock

RC arthropathy

Large irreparable RC tear

Deltoid dysfunction

Infection

Neuropathic (charcot) joint

49
Q

Describe the Walch classification of glenoid wear

A

A1: Minor central erosion

A2: Deep central erosion

B1: Posterior wear

B2: Biconcave glenoid

C: >25 degrees of retroversion

50
Q

Complications associated with RTSA (list 8)

A

Neurologic injury

Intraop periprosthetic fracture

Hematoma formation

Scapular notching

Baseplate failure

Instability/dislocation

Infection

Acromial fracture

51
Q

Indications for RTSA

A

Pseudoparalysis from cuff arthropathy

Incompetent CA arch

Age >70

Low demand patient

Intact deltoid and sufficient glenoid bone

Proximal humerus fracture

Revision TSA

52
Q

Biomechanics of RTSA

A

Medialize and distalize the COR

Valgus angle of humeral component

Inferior tilt of glenosphere (15deg)

(creates longer deltoid lever arm)

Orthopaedic Surgery (17 decks)

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