Millers - Sports Medicine - Section 4 Shoulder

Front 1

Last bone to ossify

Back 1

clavicle

Front 2

Os acromionale
- incidence?
- bilaterality?

Back 2

unfused secondary ossification center of the scapula, occurs with a 3% incidence and 60% bilaterality

The most common location is at the junction of the meso-acromion and the meta-acromion

Front 3

Most common location of Os Acromionale

Back 3

junction of the meso-acromion and the meta-acromion

Front 4

Average diameter of humeral head

Back 4

43 mm

Front 5

Orientation of humeral head

Back 5

approximately spheroidal in 90% of patients

Normally retroverted an average of 30 degrees to the transepicondylar axis of the distal humerus, with its articular surface inclined an average of 130-150 degrees superiorly relative to the shaft

Front 6

Orientation of the glenoid

Back 6

Pear shaped surface

Average upward tilt of 5 degrees and average of 7 degrees of retroversion

Front 7

Function of glenoid labrum

Back 7

deepens the socket (serves as a choke block) and anchors the inferior glenehumeral ligament complex

Front 8

Articulations of the shoulder joint

Back 8

4

Glenohumeral
Sternoclavicular
Acromioclavicular
Scapulothoracic

Front 9

Thinnest portion of the shoulder capsule

- just how thin is it?

Back 9

posterior (< 1mm)

Front 10

rotator interval

Back 10

The RI is triangular in shape and located in the anterosuperior aspect of the glenohumeral joint.

The base of the triangle is located medially at the coracoid process. The transverse humeral ligament forms the apex laterally at the intertubercular groove. The superior margin of the subscapularis tendon and the anterior margin of the supraspinatus tendon represent the inferior and superior borders of the RI, respectively.

The contents of the interval include the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), the glenohumeral capsule, and the biceps tendon

Front 11

Contents of the rotator interval

Back 11

The contents of the interval include the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), the glenohumeral capsule, and the biceps tendon

Front 12

Sternoclavicular joint

Back 12

a gliding joint with a disc that serves to anchor the shoulder girdle to the chest wall. Elevation of the arm from 0-90 degrees produces clavicular rotation about its longitudinal axis and elevation at the SC joint of 0-40 degrees. The posterior capsule is the primary restraint of excessive anterior and posterior translation.

Front 13

Primary restraint of excessive anterior and posterior translation to the SC joint.

Back 13

posterior capsule

Front 14

Acromioclavicular joint
what kind of joint is it?
what stabilizes it?

Back 14

The articulation of the scapula with the clavicle occurs through a diarthrodial joint containing an incomplete intra-articular disc. It is stabilized by the AC ligaments, which primarily resist anteroposterior translation, and the coracoclavicular (CC) ligaments, which prevent inferior translation of the coracoid and acromion from the clavicle

Front 15

Scapulothoracic joint

Back 15

The medial border of the scapula articulates with the posterior aspect of the second to seventh ribs. It is angled 30 degrees anteriorly and has a 3 degree upward tilt. There are two major ST bursae.

The ratio of GH to ST motion during shoulder abduction is approximately 2:1

Front 16

The ratio of GH to ST motion during shoulder abduction

Back 16

approximately 2:1

Front 17

Normal positioning of the scapula

Back 17

It is angled 30 degrees anteriorly and has a 3 degree upward tilt

Front 18

Static restraints of the shoulder

Back 18

Include the glenoid labrum, articular version, articular conformity, negative intra-articular pressure, capsule (posterior capsule and rotator interval), and capsuloligamentous structures

Front 19

Imbrication of the rotator interval produces?

Back 19

decreases inferior and posterior translation,

Front 20

Release of the rotator interval prodcues?

Back 20

Release produces increased forward flexion and external rotation.

Front 21

Fxn of the SGHL

Back 21

The SGHL and CHL are reinforcing structures of the rotator interval, limiting inferior translation and external rotation when the arm is adducted and posterior translation when the arm is flexed forward, adducted, and internally rotated.

Front 22

Fxn of the CHL

Back 22

The SGHL and CHL are reinforcing structures of the rotator interval, limiting inferior translation and external rotation when the arm is adducted and posterior translation when the arm is flexed forward, adducted, and internally rotated.

Front 23

Fxn of the MGHL

Back 23

The MGHL limits external rotation of the adducted humerus, inferior translation of the adducted and externally rotated humerus, and anterior and posterior translation of the partly abducted (45 degrees) and externally rotated arm.

Front 24

Fxn of the IGHL

Back 24

The IGHLC serves as the primary restraint to anterior, posterior, and inferior GH translation at 45-90 degrees of GH elevation

Front 25

Dynamic restraints of the Shoulder

Back 25

include joint concavity compression produced by synchronized contraction of the rotator cuff (RTC), acting to stabilize the humeral head within the glenoid; increased capsular tension produced by direct attachments of the RTC to the capsule; the scapular stabilizers that act to maintain a stable glenoid platform (“ball on a seal's nose”); and proprioception

Front 26

Max torque is developed during which phases of throwing?

Back 26

Maximum torque is generated during two actions—maximum external rotation (late cocking) and just after ball release (deceleration)

Front 27

The 5 phases of throwing

Back 27

Wind up
Cocking
Acceleration
Deceleration
Follow through

Front 28

Shoulder pathology more common in young patients

Back 28

Instability, AC injuries, and distal clavicle osteolysis are more common in young patients

Front 29

Shoulder pathology more common in elderly patients

Back 29

RTC tears, arthritis, and proximal humeral fractures are more common in older patients

Front 30

Instability occurs with the arm in what position?

Back 30

Instability occurs with injury to the abducted, externally rotated arm

Front 31

What must be true to evaluate the ROM of the shoulder

Back 31

Note that the scapula must be stabilized to evaluate true ROM of the glenohumeral joint.

Front 32

Standard portals for shoulder arthroscopy

Back 32

a. Posterior portal (2 cm distal and medial to the posterolateral border of the acromion, primarily used for viewing)
b. Anterior portal (just anterior to the AC joint)
c. Lateral portal (1-2 cm distal to the lateral acromial edge)

Front 33

Posterior portal for shoulder arthroscopy

- location and primary use?

Back 33

Posterior portal (2 cm distal and medial to the posterolateral border of the acromion, primarily used for viewing)

Front 34

Anterior portal for shoulder arthroscopy

Back 34

Anterior portal (just anterior to the AC joint)

Front 35

Lateral portal for shoulder arthroscopy

Back 35

Lateral portal (1-2 cm distal to the lateral acromial edge)

Front 36

Supraspinatous portal for shoulder arthroscopy

Back 36

Supraspinatus (Neviaser) portal for anterior glenoid visualization (through the supraspinatus fossa)

Front 37

Anterolateral and posterolateral portals for shoulder arthroscopy

Back 37

Anterolateral and posterolateral portals (Port of Wilmington, just anterior to the posterolateral corner of the acromion), which are useful for labral tears or superior labrum from anterior to posterior (SLAP) tears and RTC repair

Front 38

Anteroinferior portal for shoulder arthroscopy

Back 38

Anteroinferior (5 o'clock position) portal for Bankart repair and stabilization procedures

Front 39

Posteroinferior portal for shoulder arthroscopy

Back 39

Posteroinferior (7 o'clock position) portal for stabilization procedures

Front 40

Shoulder instability

Back 40

Instability is a pathologic condition manifesting as pain due to excessive translation of the humeral head on the glenoid during active shoulder motion, representing a spectrum of injury to the shoulder stabilizers

Front 41

Grading of Shoulder instability

Back 41

Grade 0 Normal small amount of humeral head translation

Grade 1 Humeral head translation to but not over the glenoid rim . Acromiohumeral interval <1 cm

Grade 2 Humeral head translation over the glenoid rim with spontaneous reduction when the applied force is withdrawn Acromiohumeral interval 1-2 cm

Grade 3 Humeral head translation with locking over the glenoid rim Acromiohumeral interval >2 cm

Front 42

TUBS syndrome

Back 42

Traumatic unilateral dislocations with a Bankart lesion often require surgery because they typically occur in young patients and have recurrence rates of up to 80-90% with nonoperative management.

Front 43

Recurrence rates of dislocation in patients with Bankart lesions

Back 43

recurrence rates of up to 80-90% in young patients with nonoperative management.

Front 44

AMBRI syndrome

Back 44

Atraumatic multidirectional bilateral shoulder dislocation/subluxation often responds to rehabilitation, and sometimes an inferior capsular shift or plication is required.

Front 45

Treatment of First-time Shoulder dislocations

Back 45

Debate still exists regarding the treatment of first-time dislocations. External rotation bracing for 3-6 weeks has been effective in decreasing the short-term rates of recurrent dislocation, at least in an Asian population. The lowest rates of recurrent dislocation (generally <10%) are seen after operative treatment, either open or arthroscopic. The newest data show that arthroscopic anterior stabilization is equivalent to open repairs. Some have advocated repair of first-time dislocations because of the decreased rate of dislocation 6 years after repair and the higher quality of life associated with operative treatment; however, this is still controversial.

Front 46

Complications of open procedures for the treatment for shoulder dislocations

Back 46

Complications of open procedures include subscapularis overtightening (Z-lengthening required) or rupture (repair or pectoralis transfer required) and hardware problem

Front 47

Thermal capsular shrinkage

Back 47

A device that delivers laser energy or radiofrequency energy to the capsule tissue causes the collagen to denature and the capsule to shrink.

The role of thermal capsular shrinkage has yet to be clearly elucidated. Good short-term results have been reported, but newer long-term results have demonstrated worsening outcomes. Poor tissue quality and chondral damage at the time of revision have been noted after thermal shrinkage. Despite this, there may still be a role for thermal shrinkage as an adjunct to capsulolabral repair.

Front 48

Posterior instability

- physical exam?
- imaging?
- treatment?

Back 48

Patients may exhibit positive load-and-shift and jerk testing.

When they are recognized, posterior dislocations respond well to acute reduction and immobilization.

Patients may present with their arms internally rotated, with observable coracoid and posterior prominence.

An axillary lateral radiograph is extremely helpful in making the diagnosis.

Rehabilitation focuses on RTC and deltoid strengthening, with surgical management (arthroscopic or open posterior Bankart repair with or without capsular shift) reserved for refractory cases.

Front 49

Kim lesion

- what is it?
- what PE exam can show it?
- imaging?
- treatment?

Back 49

This is an incomplete and concealed avulsion of the posteroinferior labrum. It may be associated with posterior and multidirectional instability.

The jerk (posterior lesion) and Kim (posteroinferior lesion) tests have been shown to be highly sensitive and specific.

An MR arthrogram can be helpful in making the diagnosis. However, the findings may be subtle or falsely negative.

After failure of conservative treatment, arthroscopic labroplasty (with a posterior capsular shift in primary posterior instability) or posterior labroplasty (with an inferior capsular shift and rotator interval closure when associated with multidirectional instability) has been effective.

Front 50

an incomplete and concealed avulsion of the posteroinferior labrum

Back 50

Kim lesion = Arrow indicates a concealed tear in the deep portion of the posteroinferior labrum. Probing reveals soft and loose attachment.

Front 51

Bankart procedure: components and complications

Back 51

Reattachment of labrum (and IGHLC) to glenoid

Gold standard

Front 52

Staple capsulorrhaphy procedure: components and complications

- very general, what is it?
- name 2 complications

Back 52

Capsular reattachment and tightening

complications include Staple migration/articular injury

Front 53

Staple capsulorrhaphy procedure: components and complications

Back 53

Components: Subscapularis advancement capsular coverage

complications: Decreased external rotation, DJD

Front 54

Magnuson-Stack procedure: components and complications

Back 54

a surgical procedure used in the correction of recurrent anterior glenohumeral joint dislocation. In this operation, the subscapularis tendon is transferred from the lesser tuberosity to the greater tuberosity

a complication of this proceudre is the resultant Decreased external rotation (my hypothesis is that hte subscap is getting stronger -> greater IR, less ER)

Front 55

Boyd-Sisk procedure: components and complications

Back 55

Transfer of biceps laterally and posteriorly to the posterior glenoid rim for the treatment of recurrent posterior dislocation,

Nonanatomic, recurrence

Front 56

Boyd-Sisk procedure: components and complications

Back 56

Transfer of biceps laterally and posteriorly

Nonanatomic, recurrence

Front 57

Boyd-Sisk procedure: components and complications

Back 57

Transfer of biceps laterally and posteriorly

Nonanatomic, recurrence

Front 58

Capsular shift procedure: components and complications

Back 58

Inferior capsule shifted superiorly—“pants over vest”

Overtightening, gold standard for MDI

Front 59

RTC disease in general

Back 59

RTC disease is a continuum beginning with mild impingement and progressing toward partial RTC tear, full-thickness RTC tear, massive tear, and finally RTC arthropathy.

Front 60

Tears associated with chronic impingement syndrome and those that occur in younger overhead athletes

Back 60

Tears associated with chronic impingement syndrome typically begin on the bursal surface or within the tendon substance, in contrast to those that occur on the articular surface because of tension failure in younger overhead athletes

Front 61

Epidemiology of RTC tear

Back 61

Millions of Americans have some aspect of RTC disease. Twenty-eight percent of those over 60 years of age have a full-thickness tear, while 65% of patients older than 70 years have a full-thickness tear. There is a 50% risk of having bilateral tears in those over 60 years old with a tear. In those with a unilateral, painful, full-thickness tear, there is a 56% chance of having an asymptomatic, contralateral, full- or partial-thickness tear. Fifty percent of those with an asymptomatic tear will develop symptoms at 3 years, and 40% of these patients may have progression of the tear.

Front 62

Symptoms of RTC tear

Back 62

Patients typically present with an insidious onset of pain exacerbated by overhead activities. Complaints of night discomfort, pain in the deltoid region, muscular weakness, and differences in active versus passive ROM are common, with more significant weakness and loss of motion indicating a higher degree of cuff involvement. Acute pain and weakness may be seen after traumatic RTC rupture. In young athletes, it is critical to exclude GH instability that causes a secondary impingement (nonoutlet impingement) from primary impingement syndrome (pathology within the subacromial space).

Front 63

Radiographic findings of RTC tear

Back 63

May demonstrate classic changes within the acromion or coracoacromial ligament (spurring and calcification) in addition to cystic changes within the greater tuberosity. With chronic RTC pathology, superior migration of the humeral head with extensive degenerative change may be present.

Front 64

Stage I RTC tear - Age (yr), Pathology, Clinical Course, Treatment

Back 64

<25 years,

Edema and hemorrhage

Reversible

Conservative

Front 65

Stage II RTC tear - Age (yr), Pathology, Clinical Course, Treatment

Back 65

25-40

Fibrosis and tendinitis

Activity-related pain

Therapy/operative

Front 66

Stage III RTC tear - Age (yr), Pathology, Clinical Course, Treatment

Back 66

>40
AC spur and cuff tear
Progressive disability
Acromioplasty/repair

Tendon degeneration is classified in 3 stages (classification of the impingement syndrome) based on the supraspinatus outlet.
Stage I - Edema and hemorrhage, affecting persons younger than 25 years
Stage II - Fibrosis and tendinitis, affecting persons aged 25-40 years
Stage III - Tears of cuff, affecting persons older than 50 years

Front 67

Nonoperative treatment of RTC tears

- who is it indicated for?
- what does it consist of?
- what adjunct treatments can you use?

Back 67

Initially indicated for impingement syndrome, chronic atraumatic cuff tears, noncompliant patients, medical contraindications to surgery, RTC arthropathy, and athletes with a combined picture of instability or cuff tearing resulting from articular-side, partial thickness failure.

Activity modification, avoiding repeated forward flexion beyond 90 degrees, and an aggressive RTC and scapular-stabilizer strengthening program are initiated.

Additionally, oral anti-inflammatory medications, therapeutic modalities, and judicious use of subacromial steroid injections may be implemented.

Front 68

Chronic impingement syndrome

Back 68

Symptoms that are refractory to a minimum of 4-6 months of nonoperative treatment may respond favorably to subacromial decompression. Similarly, patients indicated for RTC repair will often require concomitant subacromial decompression at the time of repair. Exceptions include massive, irreparable RTC tears that may benefit from d?bridement with preservation of the coracoacromial arch to prevent anterosuperior humeral migration. Additional exceptions include the acute, traumatic RTC tear or the overhead-movement athlete who may benefit from limited acromial smoothing and bursectomy, which is required for visualization and limiting postoperative irritation of the repair site.

Front 69

the rate-limiting step for recovery from RTC repair surgery

Back 69

is the biologic healing of the RTC tendon to the humerus, estimated to require a minimum of 8-12 weeks

Front 70

Evolution of operative approach of RTC repair

Back 70

The operative approach has evolved from a classic open approach, to a “mini-open” or deltoid-sparing approach, to an all-arthroscopic technique.

Front 71

Repair of Articular-side, partial-thickness RTC tears

Back 71

Treatment with d?bridement versus repair remains controversial. Considerations include the depth of the tear, the pattern of the tear (avulsion versus degeneration), the amount of footprint uncovered, and the activity level of the patient.

Front 72

Patients with a preponderance of impingement findings and a tear of less than 50% thickness may benefit from...

Back 72

debridement and subacromial decompression. Despite the excellent results reported with RTC repair, a high percentage of repairs either do not heal or re-tear. Despite this outcome, functional and subjective results remain high.

A correlation appears to exist between younger age and repair success

Front 73

Timing of repair of acute RTC repair

Back 73

Should have early repair, as the disease process is accelerated in this setting.

Front 74

Subscapularis tears

Back 74

—May occur after anterior dislocation and anterior shoulder surgery (e.g., shoulder arthroplasty). Symptoms include increased external rotation and the presence of a liftoff, modified liftoff, or belly-press sign. Surgical treatment, either open or arthroscopic, is generally indicated, with chronic cases occasionally requiring a pectoralis transfer.

Front 75

RTC arthropathy

Back 75

RTC arthropathy = RTC insufficiency, glenohumeral degenerative changes, superior migration of the humeral head. (Jensen KL, JBJS 1999;81A:1312).
Massive RTC tear and erosive arthritis of the shoulder. Humeral head migrates superiorly to abut and erode the undersurface of the acromion.
Etiology: unknown, may be calcium phosphate induced. Likely multifactorial related to: coracoacromial arch anatomy, tendon tensile overload, repetitive use, tendon vascularity, age-related degeneration.
Women > men. Dominant side > non-dominant

—Defined as a massive RTC tear combined with fixed superior migration of the humeral head and severe GH arthrosis, presumably due to chronic loss of the concavity-compression effect. Hemiarthroplasty may be helpful if the anterior deltoid is preserved. This is a good option for patients with pain as the predominant symptom. The use of a reverse shoulder prosthesis remains controversial. It requires a competent deltoid and good glenoid bone stock. It is recommended only for older patients (typically over the age of 70 years) with low functional demands. More predictable functional results are seen with the reverse prosthesis than hemiarthroplasty, but a high rate of complications (40%) has been reported with its use.

Front 76

massive RTC tear combined with fixed superior migration of the humeral head and severe GH arthrosis, presumably due to chronic loss of the concavity-compression effect.

Back 76

RTC arthropathy

Front 77

Treatment of Subcoracoid impingement

Back 77

Treatment of chronic symptoms involves resection of the lateral aspect of the coracoid process and reattachment of the conjoined tendon to the remaining coracoid. Arthroscopic coracoplasty has also been successful in treating this condition without detachment of the conjoined muscle group.

Front 78

Subcoracoid impingement

Back 78

—Patients with long or excessively laterally placed coracoid processes may have impingement of this process on the proximal humerus with forward flexion (120-130 degrees) and internal rotation of the arm. This condition may occur after surgery that causes posterior capsular tightness and loss of internal rotation. Local anesthetic injection should relieve these symptoms. A CT scan performed with the arms crossed on the chest is helpful to evaluate this problem. Less than 7 mm between the humerus and coracoid process is considered to be abnormal. Treatment of chronic symptoms involves resection of the lateral aspect of the coracoid process and reattachment of the conjoined tendon to the remaining coracoid. Arthroscopic coracoplasty has also been successful in treating this condition without detachment of the conjoined muscle group.

Front 79

Imaging to show Subcoracoid impingement

Back 79

A CT scan performed with the arms crossed on the chest is helpful to evaluate this problem.

Front 80

Bennett lesion

Back 80

a lesion of the posterior glenoid margin or rim, often seen in athletes who use throwing movements. This injury occurs as a result of posterior impingement of the humeral head on the glenoid rim, probably with traction on the posterior band of the inferior glenohumeral complex

Front 81

Internal impingement

Back 81

Impingement of the posterior labrum and cuff can occur in a throwing-motion or overhead-movement athletes with external rotation and anterior translation (secondary impingement). A Bennett lesion (glenoid exostosis) may occasionally be seen on radiographs. It is often associated with glenohumeral internal rotation deficit (GIRD) secondary to a tight posterior capsule. Glenohumeral kinematics is altered, leading to a posterosuperior shift of the humeral head, with abduction and external rotation of the arm leading to the internal impingement. This may lead to pain associated with SLAP/biceps anchor pathology a well as undersurface RTC tears of the posterior aspect of the supraspinatus and infraspinatus tendons. A “peel-back” phenomenon of the superior labrum can be appreciated intraoperatively with abduction and external rotation of the arm.

Treatment—Primary treatment should include physical therapy and avoidance of aggravating activities. Patients with GIRD may benefit from posterior capsular stretching exercises such as the sleeper stretch. Diagnosis can be aided with an MR arthrogram. An ABER view can at times show the internal impingement and associated lesions. Operative treatment includes arthroscopic d?bridement or repair of the labrum, with d?bridement of the undersurface RTC lesion. Some suggest repairing the RTC if it is significantly thinned either by using a trans-cuff technique or by taking down the remaining thinned cuff and advancing the unaffected normal tendon. A posterior capsular release can be considered in those that have GIRD and have failed to improve with nonoperative stretching.

Front 82

Internal Impingement

- what is it?
- what is its treatment?

Back 82

Impingement of the posterior labrum and cuff can occur in a throwing-motion or overhead-movement athletes with external rotation and anterior translation (secondary impingement). A Bennett lesion (glenoid exostosis) may occasionally be seen on radiographs. It is often associated with glenohumeral internal rotation deficit (GIRD) secondary to a tight posterior capsule. Glenohumeral kinematics is altered, leading to a posterosuperior shift of the humeral head, with abduction and external rotation of the arm leading to the internal impingement. This may lead to pain associated with SLAP/biceps anchor pathology a well as undersurface RTC tears of the posterior aspect of the supraspinatus and infraspinatus tendons. A “peel-back” phenomenon of the superior labrum can be appreciated intraoperatively with abduction and external rotation of the arm.

Primary treatment should include physical therapy and avoidance of aggravating activities.

Patients with GIRD may benefit from posterior capsular stretching exercises such as the sleeper stretch.

Diagnosis can be aided with an MR arthrogram. An ABER view can at times show the internal impingement and associated lesions.

Operative treatment includes arthroscopic debridement or repair of the labrum, with debridement of the undersurface RTC lesion. Some suggest repairing the RTC if it is significantly thinned either by using a trans-cuff technique or by taking down the remaining thinned cuff and advancing the unaffected normal tendon. A posterior capsular release can be considered in those that have GIRD and have failed to improve with nonoperative stretching.

Front 83

SLAP stands for

Back 83

superior labrum from anterior to posterior.

Front 84

Classification of SLAP lesions

Back 84

I - Biceps fraying, Intact anchor on superior labrum
Arthroscopic d?bridement

II Detachment of biceps anchor Reattachment/stabilization

III Bucket-handle superior labral tear; biceps intact Arthroscopic debridement

IV Bucket-handle tear of superior labrum into biceps
Repair or tenodesis of tendon based on symptoms and condition of remaining tendon

V Labral tear + SLAP Stabilize both

VI Superior flap tear
Debride

VII Capsular injury + SLAP Repair and stabilize

Front 85

Biceps tendinitis
- associated with what things?
- diagnosis is made how?
- initial treatment?
- refractory treatment?

Back 85

Often associated with impingement, RTC tears (subscapularis and leading-edge supraspinatus tears), and stenosis of the bicipital groove.

Like most other cases of “tendinitis,” this is probably best considered to be a “tendinosis.”

Diagnosis is made by direct palpation, with the arm internally rotated 10 degrees, and confirmed with Speed and Yergason tests.

Initial management includes strengthening and local injection (around but not into the tendon).

Surgical release (with or without tenodesis) is usually reserved for refractory cases.

Front 86

Biceps tendon subluxation

- associated with?
- what would you see on physical exam?
- treatment?

Back 86

This is most commonly associated with a subscapularis tear. A tear of the CHL or transverse humeral ligament may produce tendon subluxation as well. Arm abduction and external rotation may produce a palpable click with palpation as the tendon subluxates or dislocates outside of the groove.

Nonoperative treatment is similar to that for tendinitis, whereas operative treatment includes repair of the subscapularis and supporting structures of the bicipital groove but more often involves tenotomy or tenodesis.

Front 87

Diagnosis (by PE) and treatment of superior labral lesions

Back 87

In addition to biceps tenderness patients may exhibit a positive active compression (O’Brien's) test, anterior slide ( Patient stands with hands on hips. One of the examiner's hands is placed over the shouler and the other hand behind the elbow. A force is then applied anteriorly and superiorly, and the patient is asked to push back against the force. The test is positive if pain is localised to the anterosuperior aspect of the shoulder, if there is a pop or a click in that region, or if the maneuver reproduces that patient's symptoms.), or crank test. The dynamic labral shear test has recently been described, with a sensitivity of 86% and specificity of 100% in diagnosing a SLAP tear

Treatment involves debridement (types I and III) with or without stabilization of the biceps anchor (types II and IV).

Front 88

Classification of AC separations

Back 88

Type I injuries involve only an AC sprain.

Type II injuries are characterized by a complete AC tear but intact coracoclavicular (CC) ligaments.

Type III injuries involve both the AC and CC ligaments, with a CC distance of up to 100% of that of the opposite shoulder.

Type IV injuries are associated with posterior displacement of the clavicle through the trapezius muscle.

Type V injuries involve superior displacement, with a CC distance of more than twice that of the opposite side. This injury is usually associated with rupture of the deltotrapezial fascia, leaving the distal end of the clavicle subcutaneous.

Type VI injuries are rare and defined on the basis of inferior displacement of the clavicle below the coracoid.

Front 89

Treatment of type III AC separations

Back 89

Management of type III injuries is somewhat controversial, with most advocating conservative treatment and some advocating surgical reduction and repair or reconstruction. The literature suggests that those treated acutely with surgery have a higher rate of reoperation than that of primary surgery for those who are initially treated nonoperatively.

Front 90

Management of types IV through VI AC separations

Back 90

These are typically treated surgically. Note that a type V injury is defined by a coracoclavicular distance that is greater than 100% of the opposite side (bilateral AC views are required), and a type IV injury can only be diagnosed on an axillary lateral view.

Front 91

Surgical treatment of failed, conservatively treated injuries or acute treatment of AC separation

Back 91

Involves reduction of the AC joint by various methods. Coracoclavicular (CC) ligament reconstruction with a free soft tissue graft is now becoming popular to allow for an anatomic reconstruction. The distal clavicle is often resected in the chronic situation, and the CA ligament may then be transferred to the distal clavicle (modified Weaver-Dunn). Backup CC stabilization is usually required for a successful outcome. Free tendon grafts have recently been advocated for anatomic CC reconstructions.

Front 92

AC joint DJD

- risk factors?
- diagnostic work up?
- treatment options?

Back 92

Due to the transmission of large loads through a small surface area, the AC joint may begin to degenerate as early as the second decade.

Additionally, direct blows or
low-grade AC separation may cause post-traumatic arthritis.

The condition is diagnosed by direct palpation, pain elicited by crossed-chest adduction, radiographic evidence of osteophytes and joint-space narrowing, and pain relief with selective AC joint injection.

Treatment includes both open and arthroscopic distal clavicle resections (Mumford procedure).

Front 93

Treatment of AC joint DJD

(what is the eponym?)

Back 93

Treatment includes both open and arthroscopic distal clavicle resections (Mumford procedure).

Front 94

Distal clavicle osteolysis

Back 94

Common in weightlifters and those with a history of traumatic injury. Radiographs of the distal clavicle reveal osteopenia, osteolysis, tapering, and cystic changes. After failure of selective corticosteroid injection, NSAIDs, and activity modification, this condition responds favorably to distal clavicle excision (Mumford procedure)

Front 95

Sternoclavicular subluxation/dislocation

- causes?
- best tool for diagnosis?
- imaging?
- capsular anatomy?

Back 95

Often caused by motor vehicle accidents or direct trauma, this injury can be best diagnosed by CT.

Plain imaging includes the Hobbs and Serendipity views. Closed reduction is often successful.

The posterior capsule is the most important for anteroposterior translation. Anterior dislocation should be first treated with acute, closed reduction. Failed attempts and chronic dislocations are treated conservatively. Posterior dislocation should undergo closed reduction and open reduction if necessary, particularly with compression of the posterior structures. Consultation with a cardiothoracic surgeon may be appropriate. The use of hardware should be avoided whenever possible.

Front 96

Rupture of Pectoralis major

Back 96

Injury to this muscle is caused by excessive tension on a maximally eccentrically contracted muscle, often found in weightlifters. Localized swelling and ecchymosis, a palpable defect, and weakness with adduction and internal rotation are characteristic findings. Surgical repair to bone is usually necessary. Pectoralis major ruptures have not been reported in females.

Front 97

Rupture of Deltoid

Back 97

Complete rupture of this muscle is unusual, and injuries are most often strains or partial tears. Repair to bone is required for complete ruptures. Iatrogenic injury may occasionally occur during open RTC repair, with some cases requiring deltoidplasty, which consists of mobilization and anterior transfer of the middle third of the deltoid. Unfortunately, this procedure is not always possible or successful.

Front 98

Rupture of Triceps is most often associated with what?

is repair indicated?

Back 98

Ruptures of the triceps is most often associated with systemic illness (e.g., renal osteodystrophy) or steroid use. Primary repair of avulsions is indicated.

Front 99

Rupture of Latissimus dorsi

- what do you see on physical exam?
- treatment?

Back 99

This is a very rare condition exhibiting local tenderness and pain with shoulder adduction and internal rotation. Although nonoperative treatment may allow resumption of activities, operative repair has been described for the high-demand athlete.

Front 100

Calcifying tendinitis

Back 100

A self-limiting condition of unknown etiology that affects predominantly the supraspinatus tendon and occurs slightly more frequently in women.

Radiographs demonstrate characteristic calcification within the tendon.

Three stages have been elucidated: precalcific, calcific, and postcalcific. Nonoperative treatment is the rule, consisting of physical therapy, modalities, and injections. “Needling” of the lesion under image guidance has been described and is often successful. Arthroscopic or open removal of the deposit is occasionally necessary. The rotator cuff should be repaired if it is significantly involved.

Front 101

Three stages of Calcifying tendinitis

Back 101

precalcific, calcific, and postcalcific.

Front 102

Adhesive capsulitis

- what are some factors associated with its development?
- what does the essential lesion involve?
- what does arthrography demonstrate?
- treatment consists of?

Back 102

This disorder (also known as “frozen shoulder”) is characterized by pain and restricted GH joint motion.

Factors associated with the development of adhesive capsulitis include trauma after chest or breast surgery, prolonged immobilization, diabetes, thyroid disease (etiology probably autoimmune), and other medical conditions.

The essential lesion involves the CHL and the rotator interval capsule.

Arthrography may demonstrate a loss of the normal axillary recess, revealing contracture of the joint capsule. Three clinical and four arthroscopic stages have been defined

Treatment consists of a supervised physical therapy program combined with anti-inflammatory medications and/or glenohumeral steroid injections will successfully treat the majority of patients within 12 weeks.

Front 103

Clinical Stages of Adhesive Capsulitis

Back 103

Painful - Gradual onset of diffuse pain

Stiff - Decreased ROM; affects activities of daily living

Thawing - Gradual return of motion

Front 104

Arthroscopic Stages of Adhesive Capsulitis

Back 104

1 Patchy, fibrinous synovitis
2 Capsular contraction, fibrinous adhesions, synovitis
3 Increased contraction, resolving synovitis
4 Severe contraction

Front 105

Post-traumatic shoulder stiffness

Back 105

This is an asymmetrical loss of GH motion secondary to a post-traumatic or postsurgical complication due to excessive scar formation. Motion loss is related to the area of surgery or trauma and may involve the humeroscapular motion interface between the proximal humerus and overlying deltoid and conjoined tendon as well as contracture of the RTC and capsule.

Prolonged post-traumatic shoulder stiffness is unlikely to respond to nonsurgical treatment. If no improvement is seen after 12-16 weeks of nonsurgical treatment, operative intervention consisting of open or arthroscopic lysis of adhesions and manipulation under anesthesia is recommended.

Front 106

Treatment of Post-traumatic shoulder stiffness

Back 106

Prolonged post-traumatic shoulder stiffness is unlikely to respond to nonsurgical treatment. If no improvement is seen after 12-16 weeks of nonsurgical treatment, operative intervention consisting of open or arthroscopic lysis of adhesions and manipulation under anesthesia is recommended.

Front 107

GRADES OF NERVE INJURY

Back 107

1 Neurapraxia - Selective demyelination of the axon sheath

2 Axonotmesis - Disruption of axon and myelin sheath

3 Neurotmesis - Disruption of epineurium and endoneurium

Front 108

Brachial plexus injury

Back 108

Minor traction and compression injuries, commonly known by football players as “burners” or “stingers,” can be serious if they are recurrent or persist for more than a short time. Injury results from compression of the plexus between the shoulder pad and the superior medial scapula when the pad is compressed into Erb's point superior to the clavicle.

Complete resolution of symptoms is required before return to play. If burners occur more than one time, the player should be removed from competition until cervical spine radiographs can be obtained.

Three grades of nerve injury are commonly recognized. Neurapraxia, Axonotmesis, Neurotmesis

Front 109

Thoracic outlet syndrome

Back 109

Compression of the nerves and vessels that pass through the scalene muscles and first rib can result in this disorder. This condition can be associated with cervical rib, scapular ptosis, or scalene muscle abnormalities. Patients may note pain and ulnar paresthesias. Wright's test and neurological evaluation can be diagnostic. First-rib resection is occasionally required.

Front 110

Long thoracic nerve palsy

- results in?
- what are some causes?
- treatment?

Back 110

Injury to this nerve can result in medial scapular winging secondary to serratus anterior dysfunction.

This condition can be caused by a compression injury (such as that occurring in backpackers) or traction injury (as seen in weightlifters).

Simple observation is usually called for because many of these injuries spontaneously resolve within 18 months.

Treatment with a modified thoracolumbar brace may be beneficial, and (rarely) pectoralis major transfer may be required for chronic palsies that do not recover.

Front 111

Suprascapular nerve compression

- what specifically are things that can causes this?
- how would you confirm and elucidate the nature of the nerve compression?
- how would you treat?

Back 111

This nerve may become compressed by various structures, including a ganglion in the spinoglenoid notch or suprascapular notch or fracture callus in the area of the transverse scapular ligament.

Weakness and atrophy of the supraspinatus (proximal lesions) and infraspinatus are present along with pain over the dorsal aspect of the shoulder. Cysts within the spinoglenoid notch affect only the infraspinatus.

Electrodiagnostic studies and MRI may confirm and elucidate the nature of the nerve compression. Compression due to a cyst associated with a SLAP lesion may respond to arthroscopic decompression and labral repair. In the absence of a structural lesion, release of the transverse scapular ligament may provide relief.

Front 112

Quadrilateral space syndrome

Back 112

This condition is defined as axillary nerve compression within the quadrilateral space and is characterized by pain and paresthesias with overhead activity.

This is most often seen in throwing athletes and is associated with late cocking and acceleration with the abducted, extended, and externally rotated arm.

Diagnosis is confirmed by compression of the posterior humeral circumflex artery on arteriogram.

Front 113

GH DJD

- who gets it?
- what is it associated with?
- iatrogenic causes?
- radiographic w/u?
- indications for tsa?

Back 113

Although it is more common in older patients, athletes who engage in throwing may develop arthritis at a younger age than usual.

Arthritis may also be associated with other shoulder disorders, including instability and RTC disease.

Certain iatrogenic factors may also contribute to the development of osteoarthritis of the shoulder, including the use of hardware in and around the shoulder and overtightening of the shoulder capsule during shoulder reconstruction.

Radiographs, including a true anteroposterior view taken in abduction, can be helpful in characterizing the amount of arthritis. In some cases, arthroscopic d?bridement may be a temporizing measure before considering joint arthroplasty.

Progressive pain, decreased ROM, and the inability to perform activities of daily living are reasonable indications for considering prosthetic replacement.

Front 114

Scapulothoracic crepitus

Back 114

This condition is also known as “snapping scapula syndrome.”

The presentation is that of painful scapulothoracic crepitus associated with elevation of the arm.

Scapulothoracic dyskinesis may be present, and the pain is generally relieved with manual stabilization of the scapula.

Many possible causes of symptomatic crepitus exist.

Patients may respond to scapular strengthening exercises, local injections, or anti-inflammatory medications.

The differential diagnosis includes osteochondroma and elastofibroma dorsi. For more refractory cases, open or arthroscopic bursectomy and sometimes resection of the superomedial scapular border are necessary.

Front 115

Scapular winging

- what are different classes of causesh and specifics within each class?
- how is the winging direction desribed?
- what are some treatment options?

Back 115

Can occur as a result of a nerve injury, bony abnormality, muscle contracture, intra-articular pathology, or voluntarily.

The description of the direction of the winging is based on the movement of the inferior border of the scapula.

Nerve injuries include injury to the spinal accessory nerve (trapezius palsy, lateral winging), the long thoracic nerve (serratus anterior palsy, medial winging), and the dorsal scapular nerve (rhomboid palsy).

Osseous causes include osteochondromas and fracture malunions.

Selective muscle strengthening may improve winging. Surgical treatment includes lateral transfer of the levator scapulae and rhomboids (Eden-Lange procedure) for lateral winging and pectoralis major transfer for medial winging.

Front 116

Surgical treatment of scapular winging

Back 116

Surgical treatment includes lateral transfer of the levator scapulae and rhomboids (Eden-Lange procedure) for lateral winging and pectoralis major transfer for medial winging.

Front 117

Eden-Lange procedure

Back 117

lateral transfer of the levator scapulae and rhomboids for the surgical treatment of lateral scapular winging (trapezius palsy)

Front 118

Complex regional pain syndrome

Back 118

(formerly known as “reflex sympathetic dystrophy”)—As in the knee, this condition is fraught with a poor response to both conservative and surgical treatments and, in a litigious medicolegal environment, is often associated with malingering and issues of secondary gain. Diagnosis may be confirmed with a three-phase bone scan. Treatment options are numerous and may include sympathetic nerve block.

Front 119

Little Leaguer's shoulder

Back 119

This disorder commonly occurs in young baseball players and is actually a Salter-Harris type I fracture of the proximal humerus. Overuse of the shoulder as a result of failure to limit pitch count and provide periods of adequate rest are the key factors implicated in the development of this condition. It has also been suggested that breaking pitches not be thrown until after skeletal maturity is reached. Radiographs may demonstrate widening of the proximal humeral physis. MRI can assist with the diagnosis if it is in question. The condition responds to rest and activity modification, with return to play allowed when symptoms have resolved completely. Recommendations regarding age and pitch counts have been made