Shoulder Flashcards

Question

What are the advantages and disadvantages of glenoid bone grafts for management of posterior glenoid bone loss? [JBJS 2015;97:251-9]

Answer 1

Advantages * Improves version * Reestablishes joint line * Restores bone stock Disadvantages * Technically demanding * Risk of nonunion * Resorption * Subsidence

Answer 2

Advantages * Improves glenoid version * Prevents implant perforation, joint line medialization and subchondral bone loss Disadvantages * Technically demanding

Answer 3

Advantages * Improved constraint * Improved fixation

Answer 4

Wright and Cofield * Type A - near the tip and extend proximally * Type B - near the tip and extend distally * Type C - distal to the tip

Answer 5

Nonoperative * Indications * Minimally or nondisplaced * Stable humeral component * Alignment maintained in fracture brace/orthosis * Type C fractures Operative * Indications * Unacceptable alignment * Unstable humeral component * Delayed or nonunion (consider after 3 months of nonop)

Answer 6

Type A and B * Long stem prosthesis, bypass by 2-3 cortical diameters * If cemented component already inserted perform ORIF with plate and screw/cerclage Type C * Long stem prosthesis if proximal enough * ORIF with plate and screw/cerclage if too distal

Answer 7

Type A * Treat as loose component if length of fracture is similar to length of stem, \>2mm displacement, \>20° angulation * Long stem prosthesis, bypass by 2-3 cortical diameters * Augment with strut graft or plate Type B * Loose component * Long stem prosthesis, bypass by 2-3 cortical diameters * +/- Augment with cement in distal canal * +/- Augment with strut graft or plate * Stable component * ORIF with plate and screws/cerclage Type C * Trial of nonoperative * Failed nonoperative * ORIF with plate and screws/cerclage

Answer 8

1. primary OA * results in posterior glenoid wear and internal rotation contractures 2. secondary OA * infection * post-traumatic a. GH dislocatoin or subluxation b. fracture malunion * ostenecrosis * iatrogenic a. intra-articular screw penetration following ORIF b. direct mechanical injury (e.g. scope cameral or instruments) c. thermal injury (Radiofrequency devices) d. "capsulorrhaphy arthropathy" = rapid posterior chondral wear due to over tightening of the anterior capsule * glenoid dysplasia

Answer 9

1. Nonoperative * Activity modification * Pharmacological * Physical therapy * Intra-articular injections 2. Operative * Arthroscopic debridement and capsular release * CAM – comprehensive arthroscopic management * Biological replacement * Microfracture * Osteochondral autograft/allograft * ACI * Humeral arthroplasty without glenoid treatment * Full replacement * Partial replacement * Stemmed * Stemless * Humeral arthroplasty with glenoid treatment * Biologic interpositional resurfacing * Achilles allograft * Meniscus allograft * Fascia lata * Acellular dermal scaffold graft * “Ream and run” * Anatomic TSA * Corrective osteotomy of glenoid * Arthrodesis * rTSA

Answer 10

1. arthroscopic debridement and capsular release - mild OA - joint space visible on radiograph - minimal osteophyte formation and subchondral sclerosis/cysts, osteochondral lesion <2cm^2 - concentric joint space 2. biological replacement 1. focal contained chondral leson in whom the subchondral plate is maintained and the lesion is <2cm^2 in size 3. humeral arthroplasty without glenoid treatment 1. young patient with unipolar disease (glenoid preserved) 4. humeral arthroplasty with glenoid treatment 1. young patient with bipolar disease 2. ream and run can be used in eccentric glenoids as reaming can create a concentric joint 5. anatomic TSA 1. severe bipolar disease withi ntact cuff 2. low demand patient with eccentric glenoids as reaming can create a concentric joint 6. corrective osteotomy of glenoid 1. symptomatic, fixed posterior subluxation and posterior glenoid wear 7. arthrodesis 1. end-stage OA in patients with strenuous physical demands (heavy manual labor) 2. multiple failed surgeries 3. voluntary dislocators 4. failed arthroplasty 5. massive cuff tear with deltoid deficiency 6. severe neurological injury 7. chronic infection 8. rTSA 1. low demand 2. limited preop function 3. failed rotator cuff repair or other arthroplasty means 4. rotator cuff arthropathy

Answer 11

- indications - advanced symptomatic GH arthritis - young (<50yo) - active patient - desire for joint preservation - failed nonsurgical management - absolute contraindications - mild GH arthritis - nonsurgical treatment not yet attempted - incongruous joint space and severe deformity - inflammatory GH arthritis - relative contraindications - <2mm GH joint space - severely limited GH PROM (esp IR) - large osteophytes - bipolar chondral leions - low critical shoulder angle - kellgren-lawrence grade III or IV arthritis - walch B2 or C glenoid changes

Answer 12

- advantages - joint preserving - retaining native anatomy does not preclude future treatment options - delays or avoids arthroplasty - disadvantages - technically demanding procedure - additional surgery as patient may require future arthroplasty - novel procedure with unknown longterm outcomes

Answer 13

1. synovitis - synovectomy 2. adhesion - debridement 3. cartilage fraying - chondroplasty 4. loose bodies - loose body removal 5. goat’s bear deformity - inferior humeral osteoplasty 6. axillary nerve impingement and adhesions - axillary nerve neurolysis 7. capsular tightness/decrease ROM - capsular release 8. subacromial impingement - subacromial decompression 9. subacromial impingement - subcoracoid decompression 10. focal chondral defects - microfracture

Answer 14

1. Component malposition (anteversion) 2. Anterior glenoid deficiency 3. Surgical deltoid takedown 4. Axillary nerve injury 5. Failure of subscapularis repair

Answer 15

Rotator cuff deficiency

Answer 16

1. Posterior glenoid deficiency 2. Component malposition (retroversion) 3. Posterior capsular redundancy

Answer 17

1. The center of rotation must be fixed, distalized and medialized to the level of the glenoid surface 2. The prosthesis must be inherently stable 3. The lever arm of the deltoid must be effective from the start of movement 4. The glenosphere must be large and the humeral cup small to create a semiconstrained articulation

Answer 18

Bone-implant interface of the glenosphere * Maximizes compressive forces and minimizes shear forces

Answer 19

1. Scapular notching 2. Reduced ROM 3. Loss of shoulder contour

Answer 20

Mechanical impingement of the superomedial humeral prosthesis against the inferior scapular neck during adduction

Answer 21

1. sirveaux classification 1. grade 1 - defect confined to the pillar 2. grade 2 - defect extends to the lower screw 3. grade 3 - defect encompasses lower screw 4. grade 4 - defect extends under the baseplate (indicates loosening)

Answer 22

1. Eccentric inferior glenosphere position 2. Inferior inclination of the glenoid component 3. Increased lateral offset 4. Decreased inclination (neck-shaft angle) of the humeral component

Answer 23

1. Decreased notching * Inferior overhang of the glenosphere provides space between the glenosphere and scapular neck 2. Increased impingement-free ROM * Creates additional clearance between the GT and coracoacromial arch

Answer 24

Advantages * Increased ROM * Prevents impingement between the tuberosities and the coracoid process during IR and scapular spine during ER * Restores length-tension relationship and moment arm of subscapularis and teres minor Disadvantages * More stress at bone-implant interface * Glenosphere unscrewing, baseplate loosening, migration of the glenosphere

Answer 25

1. Normal Grammont inclination = 155 2. With increasing neck-shaft angles there is impingement between the polyethylene cup and inferior scapular neck

Answer 26

1. Normal Grammont retroversion = 20-40 2. With increasing retroversion there is increased ER and decreased IR before impingement

Answer 27

Full adduction * Likely due to inferior impingement which results in levering effect and distractive forces

Answer 28

1. Re-tensions the deltoid * Effective in early abduction but loses tension and subsequent strength after 90° 2. Increases the moment arm (by 20-42%) * Increases torque capacity, particularly in early abduction * Less muscle force required to generate force 3. Recruits additional fibers of the anterior and posterior deltoid * All 3 heads demonstrate primarily abductor function (nearly all fibres are lateral to center of rotation) * Native shoulder anterior fibres primarily flexors, middle fibres abductors and posterior fibres extensors * Relies on rotator cuff for rotation (may be limited if torn)

Answer 29

1. Decreases rotational moment arm of the subscapularis and teres minor 2. Decreases length-tension relationship of subscapularis and teres minor 3. May reduce active IR and ER affecting ADLs

Answer 30

- axial shuck test -axial traction on adducted humerus (optimal is 1-2mm of gapping) - lateral instability - lateral dislocation force applied with one finger on calcar (assess ease of dislocation/subluxation) - adduction deficit - gravity adduction (due to overlengthened humerus or glenoid baseplate too superior - strap muscle tightness - in neutral extension should contribute to joint compression

Answer 31

- increase poly size, - implant humeral stem proud or deep, - change glenosphere diameter, - lateralize the glenosphere

Answer 32

- improved ER - note - in both hemiarthroplasty and rTSA, healing of the GT leads to superior clinical outcomes - however, in rTSA healing of the GT is not a prerequisite for a good outcome

Answer 33

Latissimus dorsi transfer

Answer 34

1. Base of the coracoid 2. Scapular spine 3. Scapular pillar

Answer 35

1. superior humeral head migration (decreased acromiohumeral space) 2. acetabulization of the acromion 3. femoralization of the humeral head (rounding of the GT) 4. eccentric superior glenoid wear 5. osteopenia 6. snowcap sign 7. (subarticular sclerosis) 8. absence of the typical peripheral osteophytes (lack inferior and medial humeral head osteophytes)

Answer 36

Answer 37

- defined as **inability to actively elevate the arm in the presence of free PROM** and in the absence of neurologic lesions - occurs as a result of superior migration of the humeral head due to unopposed deltoid contraction in the prsence of a RC tear (loos of the inferior directed force

Answer 38

1. first line - nonop 1. PT, injections, activity modifications 2. operative 1. shoulder arthrodesis 1. indication - significant anterior deltoid deficiency, multiple previous surgeries 2. arthrscopic, debridement 1. indication - multiple medical co-morbidities, high risk patient 3. hemiarthroplasty (typically, cuff tear arthropathy (CTA) prosthesis) 1. indication - intact deltoid, intact CA ligament, FF>90, ER>30 4. rTSA 1. indication - intact deltoid, incompetent CA ligament, elderly, low demand

Answer 39

1. Symptomatic, irreparable rotator cuff tear with irrecoverable pseudoparalysis of anterior elevation and/or abduction 2. Preserved deltoid function and structure 3. Adequate glenoid bone stock and quality

Answer 40

1. Cuff tear arthropathy 2. Chronic pseudoparalysis with massive cuff tear without arthritis 3. Inflammatory arthritis with massive cuff tear 4. Proximal humerus fractures 5. Proximal humeral nonunion/malunion 6. Revision arthroplasty 7. Tumor

Answer 41

1. Deltoid dysfunction 2. Infection 3. Neuroarthropathy 4. Glenoid bone erosions or defects 5. Severe osteopenia (relative)

Answer 42

Superolateral * Advantages * Less instability * Less scapular spine and acromion fractures Deltopectoral * Advantages * Better active ER * Better glenoid component orientation * Less glenoid loosening * Less scapular notching * Easier for revision surgery

Answer 43

1. Instability 2. Periprosthetic fracture 3. Infection 4. Component loosening 5. Neural injury 6. Acromial and/or scapular fracture 7. Hematoma 8. Deltoid injury 9. Rotator cuff tear 10. VTE

Answer 44

1. Sirveaux classification * Grade 1 - defect confined to the pillar * Grade 2 - defect extends to the lower screw * Grade 3 - defect encompasses lower screw * Grade 4 - defect extends under the baseplate (indicates loosening)

Answer 45

1. Superior screw that exits at the junction of the acromion and scapular spine 2. Excessive deltoid tension 3. Osteopenia

Answer 46

Instability

Answer 47

- radiographic findings likely due to contact between the scapular neck and poly during adduction - associated with loss of baseplate fixation, poor patient outcomes and is an independent risk factor for failure - predictors of notching include - superior position of glenosphere - medialization of the center of rotation - high BMI

Answer 48

1. BMI >30 2. Subscapularis deficiency 3. Previous surgery 4. Surgical approach * Deltopectoral higher dislocation vs. superolateral 5. Bone deficiency 6. Previous trauma

Answer 49

1. Anterior (and superior) 2. Early (first 3 months)

Answer 50

Adduction, extension, internal rotation

Answer 51

1. Socket constraint * Depth of the humeral socket * Increasing the ratio of the humeral implant socket to the radius of the glenosphere head increases stability * That is, increasing the depth of the humeral socket increases stability if the glenosphere remains the same size * Also increases impingement and ROM loss 2. Eccentric (inferior) glenosphere positioning * Glenosphere should be placed as inferior as possible while ensuring good fixation 3. Glenosphere tilt * Inferior tilt 10-15° can increase stability and impingement 4. Glenosphere lateralization * Lateralization improves stability but puts more stress at the bone-implant interface * Avoid over aggressive reaming as it will medialize the glenosphere * Limit reaming to correct version and inclination 5. Humeral lengthening * Humeral lengthening improves stability * Also decreases deltoid efficiency and increases joint reaction forces * Up to 2cm of lengthening is recommended 6. Humeral lateralization * Humeral lateralization improves stability and decreases deltoid forces (reduces deltoid fatigue and acromial fractures) Note: * Glenosphere size does not affect stability * Neck shaft angle does not affect stability * Humeral and glenosphere version should be based on ROM rather than effect on stability * Recommend humeral version 0-30° * Subscapularis repair does not affect stability * Surgeon experience does not affect stability

Answer 52

1. Technique for closed reduction * Clinic or monitored setting if sedation needed * Shoulder is abducted to 45° in neutral rotation; apply longitudinal traction and posterior and inferior force to proximal humerus * Note – humerus lies anterior and superior to glenosphere 2. Three basic methods for increasing stability and deltoid tension: * Lateralizing and/or upsizing the glenosphere * Use of a retentive or more constrained polyethylene insert * Distalizing the humerus by increasing the polyethylene thickness 3. In general, the algorithm would follow: * Perform closed reduction of dislocated rTSA * Unsuccessful = open reduction * Successful = immobilize in abduction for 4-6 weeks * 1. Stable = manage nonoperative * 2. Recurrent instability = closed reduction followed by workup for etiology * Workup includes scaled full length humerus radiograph, AP and axillary radiograph, CT scan, WBC/ESR/CRP * Possible etiologies: * Infection (elevated ESR/CRP and positive aspiration) * \<3 months = I&D and liner exchange * \>3 months = one or two-stage revision * .Humeral shortening * Humeral length – measured distance between the acromion and the epicondyle compared to the contralateral side (radiographically) * \<15mm = thicker poly ± metal spacer ± retentive liner ± glenosphere change * \>15mm = humeral component revision ± proximal humeral allograft * Humeral medialization * Measured as the distance between the humeral axis and the lateral acromion * \<15mm = larger glenosphere ± increased lateral offset * \>15mm = glenoid baseplate revision with augment or lateralizing structural bone graft

Answer 53

- cutibacterium acnes (38.9%) - staph aureus 14.8% - staph epidermidis (14.5%) - coagulase-negative staph (14%)

Answer 54

- male - higher BMI - younger age - immunosuppressed conditions and meds - post-truma - rTSA - previous surgery

Answer 55

1. Bloodword 1. ESR, CRP, WBC 1. high specificity and PPV but poor sensitivity and NPV due to low-virulence infection 2. joint aspiration 1. can be performed to assess cell count and cultures 2. cutoff values have not been established in the shoulder and aspiration often does not yield enough fluid for the analysis and culture 3. tissue culture 1. arthroscopic tissue biopsy may be most beneficial in the clinical scenario of a painful arthroplasty without overt signs of infection or in the arthroplasty with presumed aseptic loosening

Answer 56

1. acute infection (timing not well defined) 1. I&D with exchange of modular components and retention of implants 2. chronic infection 1. single-stage aor two-stage revision - equivocal results in terms of infection eradication 1. 2 stage involves 1. implant removal 2. I&D, removal of cement and periarticular tissue 3. tissue culture 4. antibiotic cement spacer 5. IV antibiotics for minimum 6 wks 6. second stage reimplantation of prosthesis 2. single stage involves 1. implant removal 2. I&D, removal of cement and periarticular tissue 3. tissue culture 4. reimplantation of new prosthesis 5. IV antibiotics for 6 weeks followed by oral antibiotics

Answer 57

- ≥ 4 tissue samples - held for at least 14 days on aerobic, anaerobic and broth media

Answer 58

1. Arthroscopic debridement and capsular release * Mild OA * Joint space visible on radiograph * Minimal osteophyte formation and subchondral sclerosis/cysts * Osteochondral lesions \< 2cm² * Concentric joint 2. Biological replacement (Microfracture/ACI/Allo/Autograft) * Focal, contained chondral lesions with maintained subchondral plate and the lesion is \< 2 cm² in size 3. Humeral arthroplasty without glenoid treatment * Young patient with unipolar disease * Glenoid preserved 4. Humeral arthroplasty with glenoid treatment * Young patient with bipolar disease * Ream and run can be used in eccentric glenoids as reaming can create a concentric joint 5. Anatomic TSA * Severe bipolar disease with intact cuff * Low demand patient with eccentric or concentric glenoid 6. Corrective osteotomy of glenoid * Symptomatic, fixed posterior subluxation and posterior glenoid wear 7. Arthrodesis * End-stage OA in patients with strenuous physical demands (i.e. heavy manual labor) * Multiple failed surgeries * Voluntary dislocators * Failed arthroplasty * Massive cuff tear with deltoid deficiency * Severe neurological injury * Chronic infection 8. rTSA * Low demand * Limited preoperative function * Failed rotator cuff repair or other arthroplasty means * Rotator cuff arthropathy

Answer 59

1. Indications * Advanced symptomatic GH arthritis * Young (\<50 yr) * Active patient * Desire for joint preservation * Failed nonsurgical management 2. Absolute contraindications * Mild GH arthritis * Nonsurgical treatment not yet attempted * Incongruous joint space and severe deformity * Inflammatory glenohumeral arthritis 3. Relative contraindications * \<2 mm GH joint space * Severely limited GH PROM (especially IR) * Large osteophytes * Bipolar chondral lesions * Low critical shoulder angle * Kellgren-Lawrence grade III or IV arthritis * Walch B2 or C glenoid changes

Answer 60

Advantages * Joint preserving * Retaining native anatomy does not preclude future treatment options * Delays or avoids arthroplasty Disadvantages * Technically demanding procedure * Additional surgery as patients may require future arthroplasty * Novel procedure with unknown long-term outcomes

Answer 61

1. Synovitis = Synovectomy 2. Adhesions = Débridement 3. Cartilage fraying = Chondroplasty 4. Loose bodies = Loose body removal 5. Goat’s beard deformity = Inferior humeral osteoplasty 6. Axillary nerve impingement and adhesions = Axillary nerve neurolysis 7. Capsular tightness/decreased ROM = Capsular release 8. Subacromial impingement = Subacromial decompression 9. Subcoracoid impingement = Subcoracoid decompression 10. Focal chondral defects = Microfracture

Answer 62

1. Bony deficiency of the posteroinferior glenoid and scapular neck 2. Result of failure of ossification of secondary ossification center 3. Thickened cartilage and hypertrophic labrum found in region of bone deficiency

Answer 63

1. Asymptomatic * Nil 2. Symptomatic in absence of arthritis * Nonoperative * Operative * Open or arthroscopic labral repair or capsulorrhaphy * Glenoid reorientation (glenoplasty) * Posterior opening wedge osteotomy * Glenoid augmentation * Posterior glenoid bone grafting (autograft or allograft) 3. Symptomatic in presence of arthritis * Nonoperative * Operative * Arthroscopic debridement and capsular release (mild to moderate OA) * Hemiarthroplasty * Anatomic TSA * Augmented glenoids * Eccentric reaming (if \<15° retroversion) * Bone grafting * Glenoid osteotomy

Answer 64

1. Osteoporosis of the humeral head 2. Softening of the articular cartilage 3. Adhesion and scarring to adjacent neurovascular structures 4. Rotator cuff tears 5. Humeral head bone defects 6. Glenoid bone defects

Answer 65

1. Relatively mild shoulder discomfort 2. Limited ROM but often functional ROM * Forward elevation and abduction limitation * IR limited with anterior dislocation * ER limited with posterior dislocation

Answer 66

1. Functional limitations 2. Duration of dislocation 3. Size of the humeral head defect 4. Size of glenoid bone defect/erosion 5. Status of the articular cartilage

Answer 67

1. Limited functional demands in patient with minimal pain and can perform ADLs 2. Unacceptable surgical risk (comorbidities) 3. Unable to comply with postoperative rehab

Answer 68

1. \<4 weeks 2. Absence of large humeral head defects

Answer 69

1. Open reduction * Deltopectoral approach * Subscapularis tenotomy * Anteroinferior capsular release from humerus * Reduction of humeral head by lateral displacement and internal rotation * Address humeral head defects * \<20% * Immobilization alone * Anterior soft tissue Bankhart repair * 20-40% * Disimpaction and bone grafting * Indicated when \<3-4 weeks old * Younger patient * Allograft * Younger patient * Size-matched humeral or femoral head allograft press-fit into defect and fixed with two cancellous screws * Infraspinatus or GT transfer * Requires additional posterior approach * Smaller defects (20-25%) = infraspinatus transfer into defect * Larger defects = GT transfer * \>40% * Allograft * Younger patient * Prosthetic * Older patients * Consider in smaller defects if remaining cartilage degenerated * Place in 10-15° more retroversion than standard 3. Address glenoid defects * \>20-25% * Coracoid transfer (Latarjet) * Iliac crest autograft

Answer 70

1. Open reduction * Deltopectoral approach * Subscapularis management depends on planned procedure * Transfer – peel off LT * Allograft or prosthesis – tenotomy * LT transfer – LT osteotomy * Reduction of humeral head with external rotation * Address humeral head defects * \<20% * Immobilization alone * 20-40% * Disimpaction and bone grafting * Allograft * Subscapularis or LT transfer * \<20% = subscapularis transfer * 20-40% = LT transfer * \>40% * Allograft * Younger patients * Prosthetic * Older patients * Consider in smaller defects if remaining cartilage degenerated * Place in 10-15° less retroversion than standard

Answer 71

1. Costoclavicular (rhomboid) ligament * Strongest 2. Capsular ligaments 3. Interclavicular ligaments 4. Intra-articular disc

Answer 72

Anterior dislocation

Answer 73

1. Difficulty breathing/SOB = compression of trachea or pneumothorax 2. Dysphagia = compression of esophagus 3. Decreased ipsilateral circulation = vascular compression 4. Venous congestion in extremity or neck = vascular compression 5. Numbness or paraesthesia = brachial plexus compression \*\*\*NOTE – if symptoms present, thoracic or cardiothoracic surgery consult needed

Answer 74

Serendipity view - 40° cephalic tilt centred on SC joint

Answer 75

1. Closed reduction * Most are unstable after closed reduction * However an attempt is made because when successful it results in better cosmesis * Technique * Sedation or local anaesthetic * Supine with 3” pad between shoulders * Posterior pressure applied to medial clavicle 2. Open reduction not indicated * Risk outweighs benefit

Answer 76

1. Closed reduction * Most are stable after closed reduction * Technique * Thoracic surgeon available * Supine with 3” pad between shoulders and arm at edge of bed * Arm is abducted to be in line with clavicle * Inline traction is applied with countertraction with a sheet to the torso * The arm is then extended * If unsuccessful: * Grasp clavicle with a sterile towel clip completely around clavicle, with traction applied to arm lift the clavicle anteriorly 2. Open reduction * Indicated when closed reduction fails due to complications associated with unreduced posterior dislocations * TOS * Vascular compromise * Erosion of medial clavicle into vital structures * Technique * Incision parallel to medial clavicle * Ppreserve anterior capsule * Reduce the SC joint * If stable no further intervention * If unstable: * Medial clavicle resection and stabilization with repair to capsular ligament and periosteum * Alternative – reconstruction with semitendinosus graft in figure-of-8

Answer 77

1. Thickened and tight glenohumeral joint capsule 2. Adhesions obliterating the axillary fold 3. Capsular adhesions to itself and the anatomic neck of the humerus 4. Joint volume is diminished with minimal synovial fluid present

Answer 78

1. Chronic inflammatory infiltrate 2. Absence of synovial lining 3. Extensive subsynovial fibrosis

Answer 79

Stage 1 – Preadhesive stage * Clinical * Pain but full ROM * Pathology * Fibrinous inflammatory synovitic reaction Stage 2 – Adhesive stage * Clinical * Pain and mild loss of ROM * Pathology * Synovitis, proliferation, early adhesions Stage 3 – Maturation * Clinical * Less pain, more ROM loss * Pathology * Less synovitis, more fibrosis * Axillary fold obliterated Stage 4 – Chronic * Clinical * Severe loss of ROM, pain minimal * Pathology * Fully mature adhesions

Answer 80

1. Female 2. Age 40-60 3. Nondominant arm 4. Sedentary vocation 5. Systemic conditions * CVD, CVA, MI, thyroid disease, breast cancer treatment, diabetes * Diabetes is associated with: * Worse prognosis * Greater need for surgery * Suboptimal results

Answer 81

1. Rotator cuff strength normal 2. **Mechanical block to PROM (hallmark)** * Best assessed with ER with arm at side

Answer 82

1. Nonoperative * Physiotherapy and home exercises * Gentle progressive stretching * Intra-articular corticosteroids injection * Short term reduction in pain with no effect on ROM or long term prognosis 2. Operative * Indication: * Failure of nonoperative after 6 month trial * MUA * ER * Elevation above patients head * Reduce elevation to 90° and max IR * (Correct ER→Elevation→IR) * Arthroscopic capsular release (preferred) * Advantage * Controlled capsular release with less risks * Release: * Anterior capsule * Rotator interval * Axillary recess to 6 o’clock position * Consider posterior capsule release if loss of IR after anterior release 3. Postoperative * Immobilize arm in 90° abduction and ER for postoperative night 1 * Exercises begin POD#1 * Arm kept in abducted position for POD1+2 * Sleep in abduction for 2 weeks * Outpatient therapy continued until full motion restored and maintained

Answer 83

1. Metaphyseal comminution 2. Surgical neck translation \>33% 3. 2-part surgical neck fracture 4. Smokers 5. Significant medical comorbidities (diabetes, obesity, osteopenia)

Answer 84

1. Lack of healing 6-9 months following injury * Delayed union after 4 months 2. No interval healing on two consecutive radiographs 6-8 weeks apart

Answer 85

3-6 months post-injury if an impending nonunion is expected

Answer 86

1. Nonoperative * Indications * Medical comorbidities that preclude surgery * Minimal pain and functional losses 2. Operative * Osteosynthesis with proximal humerus locking plate and bone graft * Indications: * Good bone quality * Viable humeral head * Absence of medial calcar comminution or osteopenia * Osteosynthesis of GT or LT nonunions * Construct for large fragments and viable cuff: * Lag screws and/or buttress plates with bone graft * Construct for comminuted fragments: * Tension band techniques * Transosseous suture fixation * Suture anchor with bone graft * Fixed angle locking plate with fibular strut allograft * Indications: * Compromised medial calcar support due to comminution or osteopenia * Hemiarthroplasty, TSA, rTSA * Indication for rTSA: * Humeral head collapse and/or dysfunctional RTC * Rotator cuff atrophy * Severe tuberosity malunion or resorption * Indication for TSA: * Associated GH arthritis and intact rotator cuff

Answer 87

1. Transverse fractures \> short oblique fractures 2. Proximal diaphysis location * Greater deforming forces from deltoid and pec major * Interposed muscle and long head of biceps * Difficulty with immobilization

Answer 88

1. Nonoperative * Indications * Medical comorbidities precluding surgery * Asymptomatic nonunions or pseudoarthroses with low functional demand 2. Operative * ORIF with compression plating and autogenous bone grafting * Indications: * Standard of care in absence of prior surgery * Technique: * Anterolateral approach * Identify radial nerve between brachialis and BR * Perform neurolysis if entrapped in scar * Debride and decorticate fracture ends * **Broad 4.5mm compression plate** with 6-8 cortices above and below fracture site * Augment with ICBG (or DBM) * Dual orthogonal plating * Indications: * Fixation limited by a short proximal or distal fragment * Poor metaphyseal bone quality * Cortical strut allograft * Indications: * Severe osteopenia * Cortical allograft placed intramedullary or along medial humerus * Fixed with lateral compression plate and screws that cross the strut gaining additional cortical fixation

Answer 89

1. Dorsal side of the lateral border of the scapula 2. Posteroinferior greater tuberosity 3. Lies posterior to the rotator cable and is not associated with it

Answer 90

Posterior branch of the axillary nerve

Answer 91

1. Teres minor 2. Superolateral brachial cutaneous nerve 3. Posterior deltoid

Answer 92

1. Dynamic stabilizer 2. External rotator

Answer 93

Increased activity and subsequent hypertrophy as it must counteract the subscapularis

Answer 94

Higher levels of abduction

Answer 95

1. Patte test * Patients shoulder and elbow are flexed 90° and forearm is parallel to floor * Patient externally rotates against resistance * Positive = weakness 2. Hornblower sign * Complete inability to externally rotate with shoulder and elbow flexed 90° and forearm is parallel to floor 3. Dropping sign * Patient has arm at side with elbow at 90°, arm is externally rotated 45° * Positive = arm falls back to neutral position * Unable to maintain ER 4. External rotation lag sign * Patients elbow is flexed 90° and elevated 20 in the scapular plane * Examiner externally rotates to 5 short of maximum * Positive = lag measuring \>10 * Lag \>30° substantially related to a lesion involving the teres minor 5. Hertle drop sign * Patients shoulder and elbow are flexed 90° * Positive = forearm drops

Answer 96

External rotation lag sign with a lag \>40° * 100% sensitivity

Answer 97

1. Normal * Thickness of the muscle is equal to half the width of the glenoid 2. Hypertrophic * Thickness is greater than the width of the glenoid 3. Atrophic * Muscle belly is thin from anterior to posterior 4. Absent * Muscle is not identifiable

Answer 98

Never, always occur in conjunction with infraspinatus tear

Answer 99

1. Latissimus dorsi transfer for massive irreparable posterosuperior cuff tears 2. rTSA

Answer 100

L’Episcopo technique * Latissimus dorsi and teres major transfer * Transfer from anterior humerus to posterolateral * Change from internal rotators to external rotators

Answer 101

1. Compression of the axillary nerve in the quadrilateral space * Usually due to fibrotic bands or posterior humeral circumflex artery compression 2. Presents with shoulder pain, paraesthesia and tenderness over the quadrilateral space 3. Weakness of posterior deltoid and teres minor

Shoulder Flashcards

(127 cards)