Shoulder & Elbow Flashcards
How many degrees do you aim to make the glenoid after TSA?
neutral
In valgus extension overload, when does pain occur (throwing phase)
Deceleration phase
Outcomes of ORIF vs. TEA in displaced intra-aritcular distal humerus fracture in elderly:
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
Humeral Head Cysts are associated with what kind of soft tissue pathology?
Chronic Rotator Cuff Tear
1st & 2nd line treatments in congenital radial head dislocation
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
What type of constraint does a reverse total shoulder arthroplasty have?
Semi-constrained
AC separation classification
I: sprain
II: 25-100% displacement
III: >100% displacement
IV: Posterior
V: >300% through trapezius
VI: Subcoracoid
what are the 3 mechanisms of elbow dislocation?
Axial load: transolecranon dislocation
valgus posterolateral injury (most common)
varus posteromedial injury (coronoid fracture, tear of LCL)
What is the most important structue preventing medial subluxation of the LH biceps?
Subscapularis
Even a partial tear can lead to medial subluxation of the LHB
6 containdications for shoulder arthrodesis
Paralysis of the scapular muscles
Charcot arthropathy
Contralateral shoulder arthrodesis
Ipsilateral elbow arthrodesis
Elderly patient
Progressive neurologic disease
8 indications for shoulder fusion
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
Describe the insertion of the biceps on the radial tuberosity. What does each head do?
Long head inserts proximally
Short head inserts distally
Intra-operative options for irreparable rotator cuff tears:
tenolysis to mobilize
graft jacket
partial repair
move footprint
Bail and do tendon transfer
Greatest risk of failure of rotator cuff repair?
Age >65
NOT smoking
How do you get more ER in reverse TSA?
Reduce and get GT to heal
Concurrent tendon transfers (Lat dorsi)
ER osteotomy
Where does a reverse TSA move the center of rotation?
Medial & inferior
Cause of lateral epicondylitis:
Repeated microtraumatic tearing of ECRB
Best repair for coronoid fractures associated with terrible triad
Suture lasso technique
Better than plates/screws
Better than suture anchors
Where does the LUCL usually avulse off of?
Humeral attachment
2 ways to judge reconstruction of humeral head height
- 56mm higher than top of pec major insertion
- 7-8mm higher than GT
What is the most common location for suprascapular nerve impingement?
Suprascapular notch
Most common complications in distal biceps tendon repair/reconstruction?
Lateral antebrachial cutaneous nerve injury
- Most common in both
- new data suggests RARE in 2 incision (0-2%)
Interval for distal biceps tendon repair/
Radial: brachioradialis
Median: pronator teres
(used in both single and 2 incision techniques)
General options for correcting unstable TSA (reverse & anatomic)
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
Name 4 contraindications to TSA as per AAOS clinical practice guidelines:
- contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid)
- rotator cuff arthropathy
- irreparable cuff tears
- deltoid dysfunction
3 complications UNIQUE to reverse total shoulder arthroplasty
Scapular notching
Acromial stress fracture
Dissociation of the glenoid component (glenosphere from head)
What is the most common complication of TSA?
Axillary nerve injury
What direction of displacement of a GT fracture causes the most biomechanical dysfunction?
Posterior
as per Rouleau JAAOS 2016
What has the strongest biomechanical fixation in distal biceps tendon repair?
Endobutton
Final outcome of adhesive capsulitis?
Decreased ROM compared to contralateral shoulder
It will NOT return to normal
Classification & treatment of acromial stress fracture
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
How do you classify calcific tendinitis?
Precalcific
Calcific
- Divided into formative, resting, resorptive
Post-calcific
What is a distinctive feature of OA of the elbow?
Maintenance of joint space
However ou do get hypertrophic osteophytes
Describe the Rockwood classification for AC joint separation
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
How do you size the radial head (3 ways)
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
4 complications unique to TEA
Bushing wear
Triceps avulsion
ulnar neuropathy
instability (collaterals)
You do a rTSA and need more ER. What do you do?
Lat dorsi transfer
How do you do a load and shift test?
Supine on table.
Bring shoulder to edge of table.
Apply axial load to center humeral head.
Translate HH anterior and then posterior.
Grades:
- Translation to rim
- dislocation with spontaneous relocation
- dislocation without relocation
Outcomes of 1 incision vs. 2 incisions in distal biceps repair:
2 incisions:
greater final flexion strength
less incidence of LABC nerve injury
Treatment/surgical options
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)
Describe the order of soft tissue disruption in an elbow dislocation
Hori Circle
LCL first
then Anterior/posterior capsule
Then MCL
List 5 options to surgically treat a stiff elbow
osteophyte excision & debridement
distraction interpositional arthroplasty
total elbow arthroplasty
capsular release +/- release of posterior band of MCL indications
musculocutaneous neurectomyindications
Describe Oberlin transfer
Ulnar nerve to upper trunk for upper trunk brachial plexus injury
ie ulnar to musculocutaneous
What has more predictable results in treatment of proximal humerus fractures in the elderly?
Reverse shoulder arthroplasty
2 things that increase MCL (elbow) stress
Increased glenohumeral IR torque
Poor throwing mechanics
Isolated supraspinatus tear: can you do a TSA?
Yes
An isolated supraspinatus tear with no retraction is NOT A CONTRAINDICATION to TSA
10 year revsion free survivorship for TEA in RA?
92%
5 Physical signs of rotator cuff arthropathy
+ 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?
What percentage of patients >60 have a rotator cuff tear on imaging?
35-55%
68 year old patient with OA of shoulder and intact rotator cuff. What will give this patient most reliable pain relief?
TSA
TSA > HA in providing predictable pain relief
X-ray for AC joint separation
Zanca
What is the effect of subacromial decompression on rotator cuff repair?
None - results equivocal
What is normal glenoid version?
+5 to -12 degrees of retroversion
Causes of Elbow Contracture? (7)
rauma
surgery
arthritis
cerebral palsy
traumatic brain injury
burns
congenital conditions:
- arthrogryposis
- congenital radial head dislocation
How do you avoid scapular notching in rTSA?
inferior position & inferior tilt of glenosphere
List 5 ways to deal with posterior glenoid bone loss in an arthritic shoulder
Eccentric Reaming
Autograft (humeral head)
Augment (porous metal)
Hemiarthroplasty
Reverse total shoulder Arthroplasty
Which nerve is at risk with an inferior capsular shift (arthroscopic) and how far away from capsule is it at 6 oclock?
Axillary nerve branch to teres minor
12 mm
When do the superior, middle and inferior glenohumeral ligaments provide stability (what angle)?
SGHL: adduction
MGHL: 45 degrees abduction
IGHL: 90 degrees abduction
Think of this when they ask about structures torn in shoulder dislocations
2 absolute and 3 relative contraindications to TEA?
Absolute:
- Active infection (arthrodesis favoured)
- Charcot joint
Relative:
- Poor neurologic control of affected extremity
- Active patient <65 years
- Olecranon osteotomy
Contraindications (4) of rTSA
Deltoid deficiency (axillary nerve palsy)
Bony acromion deficiency
Glenoid osteoporosis
Active infection
After anatomic TSA, how far above the GT should the humeral head be?
5-8mm
Tendon transfer for irreparable subscap tear?
Pec Major transfer
- Pec Major transferred to LT or anteromedial GT
- Must have intact infraspinatus
How do you maximize sensitivity in intraop assessing for infection?
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
Outcomes of revision SLAP repair?
Worse than those of primary surgery
New classifiation system of GT fractures
Avulsion: fracture line perpendicular to humeral shaft
Depressed
Split: fracture line parallel to humeral shaft
Why is the anteromedial facet prone to injury in a varus posteromedial instability situation?
It gets sheared off by the trochlea
60% of it is unsupported by the ulnar shaft, making it more prone to injury
Indications for operative management of Hill-Sachs
Classic: >30-40% defect
New: Off-track lesion (engaging) no matter the size
Complications of nonop management of radial head fractures
Elbow stiffness
Insertion of MCL (elbow)
Sublime tubercle of ulnar
In proximity to coronoid
3 options for fixation in distal biceps tendon repair
All suture method
interference screw
endobutton
What open approach do you use for a posterior shoulder dislocation?
Deltopec (go from the front)
But Rouleau says anterior or posterior (JAAOS 2014)
Contraindications to TSA (6)
- 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
Whatis Friedman’s line?
Line in the plane of the scapular on the axial CT view through the glenoid
Helps you judge version
Elbow pivot shift
How do you do it?
What does it indicate?
(± 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
What are the primary restraints to posterior humeral subluxation in:
IR
ER
adduction
IR: posteriro band of IGHL
ER: subscap
Adduction: SGHL
Most common nerve injury in shoulder dislocation?
Axillary