Shoulder & Elbow

Question 1

What is the best treatment option for anterior glenoid bone deficiency (inverted pear glenoid) from a large bony Bankart lesion?

Answer 1

Bony augmentation using the Latarjet vascularized coracoid transfer.
-Patients with glenoid bone defects >20-30% have a high recurrence rate (>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling) and iliac crest bone grafting.

Question 2

When is humeral head bone augmentation useful?

Answer 2

Engaging Hill Sachs lesions

Question 3

Remplissage

Answer 3

soft tissue filling procedure (posterior capsulodesis and infraspinatus tenodesis) which addresses engaging Hill Sachs lesions

Question 4

The Connolly procedure

Answer 4

involves transfer of the infraspinatus and attached greater tuberosity bone block into a Hill Sachs lesion. It is analogous to the Neer-McLaughlin transfer (subscapularis and lesser tuberosity for reverse Hill Sachs lesions) in posterior instability

Question 5

PASTA lesion

Answer 5

• partial articular surface tendon avulsion (PASTA) lesion of the supraspinatus
• can be difficult to diagnose and intra-articular contrast can help to delineate the pathology

Question 6

ALPSA lesion

Answer 6

• Anterior labral periosteal sleeve avulsion (ALPSA)
• where the labral-ligamentous complex is displaced medially and shifted inferiorly, rolling up on itself underneath intact periosteum

Question 7

GLAD lesion

Answer 7

• Glenolabral articular disruption (GLAD)

- tear of the anterior inferior labrum (nondisplaced) with avulsion of the adjacent glenoid cartilage

Question 8

HAGL lesion

Answer 8

• Humeral avulsion of the glenohumeral ligament

- where the inferior glenohumeral ligament avulses from the inferior humeral neck

Question 9

SLAP tear

Answer 9

-Superior labral anterior to posterior to the biceps root tears

Question 10

Brachial neuritis

Answer 10

• aka Parsonage-Turner syndrome

- rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity

Question 11

Which surgical reconstruction technique has been shown to result in the lowest complication rate and best patient outcome for reconstruction of the ulnar collateral ligament?

Answer 11

• UCL reconstruction using a flexor-pronator muscle-splitting approach and a docking graft fixation technique WITHOUT ulnar nerve transposition are associated with the lowest complication rate and best patient outcomes
• NOTE: the figure of 8 technique is NOT associated with better patient outcomes when compared to the docking technique. Also, obligatory ulnar nerve transposition during UCL reconstruction is associated with a HIGHER rate post-op ulnar neuropathy and worse patient outcomes, and should be avoided.

Question 12

which partial rotator cuff tears are best managed with conversion to a complete tear and repair rather than debridement?

Answer 12

• Partial rotator cuff tears that are > 3mm depth on the bursal side and > 6mm depth on the articular side should be managed with conversion to a complete tear and subsequent repair.
• Tears on the bursal surface are felt to be less well-tolerated because they are on the highest tension side.
• The articular surface of the rotator cuff has decreased vascularity and tensile strength compared to the bursal surface. Therefore, articular-sided partial RCTs are often due to degenerative tendinopathy in older patients and tensile failure in younger patients, particularly overhead throwing athletes. Bursal-sided tears are most commonly associated with extrinsic impingement of the acromion and the coracoacromial ligament.

Question 13

Standard of care for partial tear of biceps tendon refractory to non-op management?

Answer 13

Open detachment, debridement, and reattachment of the biceps tendon

Question 14

Which pathologic entity is most often encountered in association with the clinical diagnosis of internal impingement of the shoulder?

Answer 14

• SLAP tear
• SLAP tear with posterior extension of the labral detachment is felt to be an important aspect of pathology in internal impingement, Whether this is the cause of condition or a result of the altered glenohumeral mechanics is still debated.

Question 15

What’s the diagnosis when a patient lacks both active and passive motion in all planes of shoulder motion?

Answer 15

Adhesive capsulitis

-Tx is regimen of stretching exercises for motion

Question 16

Options for takedown of the subscapularis during TSA?

Answer 16

Tenotomy, subscap peel, or lesser tuberosity osteotomy

Question 17

Physical exam finding of fixed posterior shoulder dislocation?

Answer 17

Lack of external rotation

-Always obtain an axillary view on any patient with a shoulder injury!!!

Question 18

Treatment of choice for unstable symptomatic sternoclavicular joint?

Answer 18

-Semitendinosis figure of eight graft
Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.

Question 19

The most likely concern, in a patient older than age 40 having a first-time shoulder dislocation, is….?

Answer 19

Rotator cuff tear

Question 20

The “sleeper stretch” is what and addresses what pathology?

Answer 20

• stretches the contracted posterior soft tissues in pts demonstrating symptoms of internal impingement or GIRD
• typically stretches the posterior band of the inferior glenohumeral ligament

Question 21

Internal impingement

Answer 21

• significant cause of pain in throwing athletes. It results from impingement of the articular undersurface of the posterior supraspinatus against the posterior-superior glenoid. This is thought to be secondary to tightness in the posterior soft tissues including the capsule and posterior band of the IGHL. The mainstay of non-operative management is posterior capsular stretching with the sleeper stretches and cross-body adduction stretches
• repetitive contact between greater tuberosity and glenoid rim postero-superiorly lead to impingement of the posterior rotator cuff and labrum. This occurs when the arm is externally rotated and abducted.

Question 22

Multidirectional instability (MDI)

Answer 22

• common physical exam findings is increased external rotation in adduction
• generalized ligamentous laxity and an incompetent rotator interval (think sulcus sign)
• Patients will often present with a history of atraumatic shoulder instability events that were easily reduced. Diagnosis often includes a thorough evaluation of systemic laxity (Beighton’s score) as well as multidirectional shoulder instability (posterior, anterior, and inferior). The exam finding of an increase in external rotation in adduction corresponds with an incompetent rotator interval. The mainstay of treatment is physical therapy with surgical stabilization reserved for recalcitrant cases.

Question 23

Cross-body adduction test

Answer 23

-elicits pain when there is an associated AC joint pathology

Question 24

O’Brien’s test

Answer 24

-possible SLAP tear when a deep pain is elicited

Question 25

Axillary webbing

Answer 25

-can be seen in setting of a PEC MAJOR RUPTURE

Question 26

Jobe’s test

Answer 26

-elicits weakness or pain in the setting of supraspinatus pathology

Question 27

Key physical exam findings for subscapularis tear

Answer 27

The key physical exam findings are positive Belly-press and Lift-off maneuvers, as well as weakness in internal rotation and increased passive external rotation. The MRI confirms the diagnosis with discontinuity of the subscapularis and the long-head of the biceps not located in the bicipital groove.

Question 28

open vs arthroscopic distal clavicle excision?

Answer 28

Only cited difference is ability to evaluate the glenohumeral joint in arthroscopic DCE compared to open. Potential for missing SLAP lesions reported in literature

Question 29

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder?

Answer 29

• Tight posterior capsule with a NORMAL TOTAL ARC OF MOTION (increased ER and decreased IR = normal total arc)
• Pitchers change rotation during adolescent growth with external rotation of the proximal humerus. The result is increased external rotation and decreased internal rotation, resulting in a normal total arc of motion. External rotation lengthens the arc of acceleration, resulting in increased velocity. The shorter arc of internal rotation, associated with a tight posterior capsule, makes deceleration of the arm more difficult, which may lead to overuse injuries.

Question 30

Best MRI sequence to view quality of muscle in rotator cuff?

Answer 30

Sagittal T1-weighted MRI

Question 31

Decreased risk of shoulder and elbow injury in a throwing athlete has been demonstrated with which of the following?

Answer 31

• Posterior capsular stretching
• Posterior capsular contracture has been demonstrated to significantly impair the ability of the humeral head to translate anterior and inferiorly during the late cocking and early acceleration phases of the throwing motion.
• This results in an obligatory posterosuperior translation of the humeral head that may contribute to posterior superior glenohumeral internal impingement with posterosuperior labral and articular-sided rotator cuff pathology. Posterior capsular stretching in throwing athletes has been demonstrated to decrease the likelihood of clinically significant shoulder or elbow injury.

Question 32

Osteochondritis dissecans of the elbow

Answer 32

• occurs in the older child or adolescent (typically older than age 13 years).
• etiology is felt to be microtraumatic vascular insufficiency from repetitive rotatory and compressive forces. MRI typically shows separation of cartilage from the capitellum and chondral fissuring.
• Do not confuse with PANNER’S DISEASE, which is usually seen in children younger than age 10 years, and involves the entire capitellar ossific nucleus and resolves typically with no residual deformity or late sequelae

Question 33

Most common structure in shoulder involved in calcific tendinitis?

Answer 33

Supraspinatus tendon

• “Pre-calcific” stage shows metaplasia of tenocytes into chondrocytes. The “Calcific” stage has three sub-parts: Formative phase, Resting phase, Resorptive phase. The “Post-calcific” stage is last.
• Two types are seen on X-Ray: Type I has as fluffy and fleecy appearance with a poorly defined periphery. This is associated with an acute pain and is usually seen during the formative phase of the calcific stage. Type II is characterized by discrete homogeneous deposits with uniform density and a well defined periphery. This is seen in subacute and chronic cases. Persistent cases may respond to arthroscopic debridement of the deposits with a shaver or spinal needle.