Upper Extremity Flashcards

Question

Describe you approach to elbow arthroscopy

Answer 1

* Lateral decutibus position on a beanbag and an axiallary roll * Saddle bolster under arm with tourniequtte * Mark out the ulnar nerve (assess whether it subluxes), and boney prominences * Inflate the joint with 20 mL of saline in the lateral soft spot * anteromedial portal is created first with sharp incision through the skin and blunt disection * anterolateral is the working portal and is created under direct visualization * use any adjunct portals you might need to removes osteophytes, loose bodies; may need to release capsule to gain ROM * then go posterior via posteolateral portal and one central to clean the pathology at the back * post-op * brachial plexus block PRN * CPM machine if needed * early ROM * indomethecin 25mg TID

Answer 2

* **Can be seen in** * association with dominant hand * men to women 4:1 * middle aged laborers * MUCL or ligamentous insufficiency * **Etiologies** * _rheumatoid arthritis_ * most prevalent form with 50% of patients affected * causes progressive bone resorption and osteopenia * _post-traumatic arthritis_ * second most common form * _primary arthritis_ * rare * common in middle-aged male laborers * _history of osteochondritis dissecans_

Answer 3

* **History** * progressive pain * loss of terminal extension or flexion * painful locking of elbow * Will progress from pain at end-arc to pain through-out ROM * History of trauma, throwing/sports/labour, instability * PMHx - RA, OCD * **Physical exam** * loss of elbow range of motion * ligamentous incompetence can be seen * especially in rheumatoid arthritis * ulnar neuropathy present in up to 50% of patients * **Radiographs** * elbow joint space narrowing * Usually have more preserved anatomy than seen with other joints * osteophytes - most prominent finding * coronoid process and fossa * especially in olecranon tip and posteromedial olecranon fossa * loose bodies * **CT scan** * can help better define osteophytes and loose bodies * Especially shelf osteophytes in the olecranon fossa, radial fossa and coronoid fossa * Can help you see osteophytes around the ulnar nerve

Answer 4

**Elbow OA** * **NSAIDS, cortisone injections, resting splints, and activity modification** * _indications_ * mild to moderate symptoms * \< 15 deg of motion loss * **Arthroscopic or open debridement and capsular release** * _indications_ * mild disease with bone spurs * mechanical block to motion * preferred in patients with \>90 degrees of motion * _technique_ * removal of osteophytes and loose bodies * often combined with soft tissue release * Radial head is only resected if it is causing severely limited ROM * _Outcomes_ * Improved with symptoms \< 1 yr * Arthroscopy = better pain relief * Open = better gain in ROM * **ulnohumeral distraction interposition arthroplasty** * _indications_ * young high demand patients * Who don't want to comply with TEA restrictions * _technique_ * Posterior approach * Minimal debridement of articular surface * can use * autogenous tensor fascia lata * achilles tendon allograft * patients with severely limited preoperative motion (extension \> 60 degrees and flexion of \< 100 degrees are at risk for ulnar nerve dysfunction postoperatively * should undergo a concomitant ulnar nerve decompression * Hinged external fixation is used to allow immediate ROM * Removed after 4 weeks * _Outcomes_ * Better outcomes with TEA, especially for post-traumatic * **olecranon fossa debridement (Outerbridge-Kashiwagi procedure)** * _indications_ * younger patients with decreased ROM * _technique_ * Posterio-medial approach, identify the ulnar nerve * burr hole through olecranon fossa * removes osteophytes and arthritic bone anteriorly threw the hole * increases range of motion * be sure to decompress the ulnar nerve if there is an extension contracture preoperatively * **total elbow arthroplasty** * indications * _older patients \>65 years_ with _severe elbow arthritis_ * complex distal humerus fracture in elderly with poor bone stock * _Semi-constrained_ * Most commonly used * Linked so that they don't dislocated with some strain that is taken by the soft tissue/ligaments * _Convertible_ * Can be converted to linked if becomes unstable * Can be converted to unlinked once some rehab has been done * _unconstrained TEA_ * used with competent elbow ligaments and adequate bone stock * Can have problems with instability, maltracking, subulxation * _constrained TEA_ * used with incompetent elbow ligaments * Either triceps sparing or bryan-morrey apparoch * Immobilized in extension for 48 hrs * Start early active ROM * If triceps has been detached then avoid active extension for 6 weeks * **Complications** * Instabiltiy * Infection * Fracture * HO * Ulnar nerve neruopraxia

Answer 5

* Painful OA with loss of 30-130 degree of motion * Lateral decubitus with a bolster under the arm * Lateral column approach * ECRB and BR * elevate off the anteiror humerus and the capsule * remove the lateral portion of the capsule * then elevate the triceps off posteriorly * open the posterior capsule and debride the olecranon fossa and the olecranon * Medial approach * transpose the ulnar nerve * \>30 deg release * \<90 deg of flexion * can release the posterior bundle of the MCL to help get more flexion * Post-op * splint for comfort with early ROM

Answer 6

total elbow arthroplasty indications older patients \>65 years with severe elbow arthritis complex distal humerus fracture in elderly with poor bone stock Semi-constrained Most commonly used Linked so that they don't dislocated with some strain that is taken by the soft tissue/ligaments Convertible Can be converted to linked if becomes unstable Can be converted to unlinked once some rehab has been done unconstrained TEA used with competent elbow ligaments and adequate bone stock Can have problems with instability, maltracking, subulxation constrained TEA used with incompetent elbow ligaments Either triceps sparing or bryan-morrey apparoch Immobilized in extension for 48 hrs Start early active ROM If triceps has been detached then avoid active extension for 6 weeks Complications Instabiltiy Infection Fracture HO Ulnar nerve neruopraxia

Answer 7

* **Anterior one-incision technique** * _technique_ * transverse incision made over antecubital fossa * interval between brachioradialis laterally and the pronator teres medially * supinate forearm expose tuberosity and protect PIN * _complications_ * **injury to the lateral antebrachial cutaneous nerve** is most common * injury to radial nerve is most severe * synostosis and resulting loss of pronation/supination * avoid exposing periosteum of ulna * avoid dissection between the radius and ulna * heterotopic ossification * _postoperative_ * immobilize in 110° of flexion and moderate supination * **Two-incision technique (Boyd-Anderson)** * recommended by most * technique * uses smaller anterior incision over antecubital fossa and a second posterolateral elbow incision * anterior dissection is same as single incision described above * after radial tuberosity exposed, blunt hemostat passed along medial border towards dorsolateral proximal forearm * hemostat pierces aconeus and tents skin indicating where posterolateral incision should be made * tendon is passed between radius and ulna and attached to radial tuberosity * **regain more flexion** * _complications_ * lateral antebrachial cutaneous nerve is most common less common * by using two incisions you avoid deep dissection in the antecubital fossa and minimize risk to the radial nerve * **synostosis and HO are more common**

Answer 8

will lose 40-50% supination will lose ~30% flexion will lose 15% grip strength ## Footnote *Non-operative for elderly or for someone who doesn't need strength*

Answer 9

* Biceps inserts on radial tuberosity * 21 mm total * **long head more for supnation** * _Proximal and radial_ * **Short head more for flexion** * _Distal and ulnar_ * Lacertus originates from the short head * Complete vs Partial * _Parital usually occurs on the radial side_ * Intersubstance transection * Mechanism of tear * eccentric contraction at 90 deg flexion

Answer 10

* **History ** * patient often hears a pop * **Symptoms ** * pain in antecubital fossa * **Physical exam ** * inspection and palpation * popeye deformity (muscle bulges appearing more prominent) * for distal rupture, may be referred to as a "reverse" popeye * palpable defect * hook test * With a partial tear or no tear (strain) the examiner will be able to get their finger under the tendon near the insertion. * tenderness at biceps insertion * neuromuscular * loss of supination/flexion strength * lose more supination than flexion, up to 50% * challenge is to distinguish between complete tear and partial tear. * biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they have a very similar clinical picture) * **Radiographs ** * usually normal * **MRI is important to distinguish between ** * complete tear vs. partial tear * muscle substance vs. tendon tear * degree of retraction

Answer 11

* No breaking pitches (curveball, sliders) until puberty (approximately age 13 y) * Proper pitching mechanics in youth and year-round physical conditioning should be stressed. * Discourage youth from pitching for more than one team in a season. * Three-month rest period per year from overhead throwing activities * No pitching in a game or practice after being removed from pitching in a game.

Answer 12

* **SGHL** * restraint to inferior translation at 0° degrees of abduction (neutral rotation) * **MGHL** * resist anterior and posterior translation in the midrange of abduction (~45°) in ER * **IGHL** * _posterior band IGHL_ * most important restraint to posterior subluxation at 90° flexion and IR * tightness leads to internal impingement and increased shear forces on superior labrum (linked to SLAP lesions) * _anterior band IGHL_ * primary restraint to anterior/inferior translation 90° abduction and maximum ER (late cocking phase of throwing) * anchors into anterior labrum * forms weak link that predisposes to Bankart lesions * _superior band IGHL_ * ***most important static stabilizer about the joint*** * 100% increased strain on superior band of IGHL in presence of a SLAP lesion * **Coracohumeral ligament (CHL)** * limits posterior translation with shoulder in flexion,adduction, and internal rotation * limits inferior translation and external rotation at adducted position

Answer 13

* LACN most commonly * PIN and superficial radial nerve * two incision technique was supposed to reduce this, but now with smaller anterior incision it is low with both * synosteosis * HO

Answer 14

* **Formative** - chronic pain with deposition * **Resting** - less painful * **Resorptive** - acutely painful, mimics infection

Answer 15

* **PT** * to maintain joint mobility * always do this first * **intrabursal cortisone injection** * during formative phase * **Needle lavage** * resorptive phase * offered by author after 3 months - injection of bupivicane, 3-5 passes with 18 guage * **Extracorpeal shock-wave** * sill a lot of research necessary * **Surgery - arthroscopic vs miniopen decompression**

Answer 16

* **progression of symptoms** - following 6 months of trial of PT the USNL * **interference with ADLs** * **refractory to nonoperative treatment** * **rarely indicated during resorptive phase**

Answer 17

* clavicle, first rib, subclavius muscle, costoclavicular ligament, and anterior scalene muscle * junction of lower trunk and first rib * Brachial plexus and subclavian vessels travel between anterior and middle scalene * more often neuro compression occurs * rarely vascular compression occurs; this requires heparinizaiton and surgical treatment * **Physical** * _Wright_ * _abduction and external rotation_ with the neck rotated away leads to loss of pulse and reproduction of symptoms * _Adson_ * extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling * _Roos_ * hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms * **_CXR_** * most common finding is a _cervical rib_ * assess for pancoast tumor

Answer 18

* **neurologic decompression** * _indications_ * neurogenic etiology * nonoperative modalities have failed * progressive and severe neurologic deficits and pain * _technique:_ address site of compression * repair clavicle malunion * transaxillary first rib resection (90% good to excellent results) * scalene takedown * pectoralis minor tenotomy * release of fibromuscular anomalous bands * **vascular reconstruction (open or interventionally)** * _indications_ * subclavian aneurysm present * persistent insufficient vascularity

Answer 19

diabetes ``` thyroid disorders (autoimmune etiology) previous surgery (lung and breast) prolonged immobilization extended hospitalization ```

Answer 20

* **Clinical Stages** * Painful * Gradual onset of diffuse pain (6 wks to 9 mos) * Stiff * Decreased ROM affecting activities of daily living (4 to 9 mos or more) * Thawing * Gradual return of motion (5 to 26 mos) * **Arthroscopic Stages** * Stage 1 * Patchy, fibrinous synovitis * Stage 2 * Capsular contraction and fibrinous adhesions * Stage 3 * Increasing contraction, synovitis resolving * Stage 4 * Severe contraction

Answer 21

* Pain in all ROM, limited PROM * XR may show associated calcification or hardware * MR arthrogram may show loss of the axillary recess * **NSAIDs, physical therapy, and intra-articular steroid injections** * physical therapy * program of gentle, pain-free stretching and moist heat * should be supervised and last for 3-6 months * results * successful in vast majority although patience is required * most common complication is decreased range of motion compared to contralateral extremity * **manipulation under anesthesia (MUA)** * indications * failure to improve with therapy and NSAIDs * surgical techniques * may be combined with arthroscopic surgical release * **arthroscopic surgical release** * indications * only after extensive therapy has failed ( 3-6 months) * technique * arthroscopic rotator interval release will increase ER * superior glenohumeral and coracohumeral ligaments * arthroscopic posterior capsular release will increase IR

Answer 22

* helps to maintain the stability of the joint * strains the IGHL without it * Buford complex is a normal anatomical variant * Pathoanatomy * forceful traction * repetative throwing * direct compression * Physical exam * no specific exam is useful * O'briens, yeargson and speed can be helpful * assess the cuff * Assess for associated spinoglenoid compression

Answer 23

Stage I Normal x-ray. Changes on MRI Stage II Sclerosis (wedged, mottled), osteopenia Stage III Crescent sign indicating a subchondral fracture Stage IV Flattening and collapse Stage V Degenerative changes extend to glenoid

Answer 24

* In a young patient, arthroscopic debridement can be used as a temporizing measure to improve ROM * more to release the capsule and the rotator interval than debride the osteophytes * \>50 * good glenoid bone * TSA * Inadequate glenoid bone * stemmed or unstemed hemiarthroplasty * \< 50; manual labourer * resurfacing * stemmed hemiarthroplasty * biological resurfacing * Stage II/III AVN * stemmed hemiarthroplasty * proximal humerus malunion * TSA with resurfacing and glenoid resurfacing

Answer 25

* **Indications** * primary arthritis * rotator cuff is deficient * glenoid bone stock is inadequate * risk of glenoid loosening is high * young patients * active laborers * rotator cuff arthropathy * hemiarthroplasty \> rTSA if able to achieve forward flexion \> 90 degrees * osteonecrosis without glenoid involvement * proximal humerus fractures * three-part fractures with poor bone quality * four-part fractures * head-splitting fractures * fracture with significant destruction of the articular surface * **Contraindications** * infection * neuropathic joint * unmotivated patient * coracoacromial ligament deficiency

Answer 26

* **Approach** * deltopectoral approach * **Shaft preparation and prosthesis placement** * humeral head resection * start osteotomy at medial insertion line of supraspinatus * determine retroversion, implant height and head size * 30° of retroversion is ideal as reference from the fin to the biceps * *inappropriate version will lead to instability* * implant height * greater tuberosity should be * 3-5 mm below top of humerus * 10 mm below articular surface of humeral head * distance from top of prosthesis head to upper border of pectoralis major should be 56mm * head size * radiograph of contralateral shoulder * measuring size of native head removed earlier in procedure * *using too large of a head may "overstuff" joint* * **Fixation** * cemented prosthesis * standard of care * provides better quality of life, range of motion, and strength compared to uncemented humeral component * **Tuberosity reduction** * tuberosity migration is one of the most common causes of failure for fractures treated with hemiarthroplasty * technique * strict attention to securing the tuberosities to each other and to the shaft * autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates * tuberosity reduction must be anatomic or it may lead to a deficit in rotation

Answer 27

* Beachchair at 45 deg * Prep both anterior and posterior * 12cm incision from coracoid to the deltoid insertion * find the cephalic vein and retract laterally * incise the clavipectoral fascia and retract the deltoid laterally * Identify the pec major inferiorly, and the conjoint tendon superiorly, be aware of the musculocutaneus nerve * Identify the superior and inferior margins of the subscap, be aware of the axillary nerve along the inferior margin * Release the subscap leaving some tendon to sew back to

Answer 28

* Early passive motion until fracture has healed * duration usually 6-8 weeks * Strengthening exercises begin once tuberosity has fully healed

Answer 29

* **Progressive glenoid arthrosis** * increased risk with * young patients * active patient * treatment * conversion to total shoulder arthroplasty * **Tuberosity displacement/malunion** * one of the most common complications of shoulder hemiarthroplasty when used to treat fracture * treatment * repositioning of the tuberosity with bone grafting * **Joint overstuffing** * may lead to * stiffness * accelerated arthritis of glenoid * **Subcutaneous (anterosuperior) escape** * occurs when both rotator cuff and coracoacromial arch are deficient

Answer 30

* **rotator cuff intact and functional** * due to proximal migration * do rTSA or hemi * an isolated supraspinatus tear without retraction can proceed with TSA * _incidence of full thickness rotator cuff tears in patients getting a TSA is 5% to 10%_ * if positive impingement signs on exam, order a pre-operative MRI * **glenoid bone stock and version** * if glenoid is eroded down to _coracoid process_ then glenoid resurfacing is contraindicated

Answer 31

**Defect length** – measure the length of the fragment Width:length = normal = 0.7 **W:H** Lower ratio = greater bone loss * *Inverted pear** * *Glenoid index** Maximum width compared to contralateral width **Glenoid ratio** d/r distance to center of deficiency over radius of glenoid **Perfect Circle** draw a circe and estimate the percent lost from the circle **Pico method** 3D is gold standard

Answer 32

* pain relief most predictive benefit (more predictable than hemiarthroplasty) * reliable range of motion * good survival at 10 years (93%) * good longevity with cemented and press-fit humeral components * worse results for post-capsulorrhaphy arthropathy

Answer 33

* **Deltopectoral** * detach the subscapularis and capsule from anterior humerus * dislocate shoulder anteriorly * may require release of the upper half of the pectoralis tendon * _Complications_ * axillary nerve damage is the most common complication * axillary nerve and posterior humeral circumflex artery pass beneath the glenohumeral joint in the quadrilateral space * **Capsule** * anterior capsule contracture (passive ER \< 40°) * treatment * anterior release and Z-lengthening * posterior capsule stretching * treatment * volume-reducing procedure (plication of posterior capsule) * **Glenoid deficiency and retroversion** * Goal is a 5-10 retroversion * Options * single stage * two stages with reaming and grafting * ream and run * glenoid deficiency * autograft (head or iliac crest) * metal augments * eccentric ream (10 deg) * **Glenoid component - all poly pegged, cemented** * convex superior to flat * recreate neutral version * peg design is biomechanically superior to keel design * polyethylene-backed components superior to metal-backed components * uncemented glenoid has a lower rate of loosening * conforming vs. nonconforming * both have advantages and neither is superior * conforming is more stable but leads to rim stress and radiolucencies * nonconforming leads to increased polyethylene wear * **Humeral stem fixation** * cemented stem or uncemented porous-coated implants * ream on hand to prevent notching and fractures * 9mm lateral to center of humeral head will ensure proper trajectory and decreased risk of fracture * position of _humeral stem should be 25-45°_ of retroversion * *if position of glenoid retroversion is required, then the humeral stem should be less retroverted to avoid posterior dislocation* * causes of increase joint reaction forces and tension on the RC * valgus positioning * avoid overstuffing * the top of the humeral head should be 5 to 8 mm superior to the top of the greater tuberosity * **intraoperative humerus fracture** * _prevention_ * __gentle positioning * higher risk with revision cases and osteopenic bone * hand ream * _greater tuberosity fracture_ * if minimally displaced, insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture * _humeral shaft fracture_ * remove prosthesis and add longer stem with cement and reinforce with cerclage wiring * bypass 2-3 cortical diameters * can cement the distal end * use allograft strut if there is severe osteopenia * if you don't have a stem long enough you can fix it without passing the stem, just make sure you don't have a stress riser * **Closure** * ****drill 3 holes * then use bone tunnel fixation with a small plate to prevent cutout threw the cuff

Answer 34

* **Glenoid loosening** * most common cause of TSA failure (30% of primary OA revisions) * _risk factors_ * insufficient glenoid bone stock * rotator cuff deficiency * 2.9% reoperation rate for loosening (28% with revision) * radiographic lines - progression (not presence) correlates with symptoms * **Humeral stem loosening** * more common in RA and osteonecrosis * rule out infection * **Subscapularis repair failure** * **Malposition of components** * **Improper soft tissue balancing** * failure due to undiagnosed presence of rotator cuff tears * **Iatrogenic rotator cuff injury** * can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion * **Stiffness** * **Infection** * early infection (\<6 weeks) can be treated with open irrigation and debridement * late infection (\>6 weeks) should be treated by explant and staged reimplantation after IV antibiotic course * _Propionibacterium acnes (P. acnes)_ * high bacterial burden around the shoulder * common cause of indolent infections and implant failures * **Neurologic injury** * axillary nerve is most commonly injured * musculocutaneous nerve can be injured by retractor placement under conjoint tendon

Answer 35

* wear to the coracoid means not enough bone to do the glenoid * 3D CT to assess bone stalk of the glenoid * draw a line from the sapula, use the articular surface as neutral and determine the differnece of the glenoid * a dysplastic glenoid (type C), the humeral head is concentric in the glenoid; * use a centralized guide wire into the scapula to ensure correct version * eccentric reaming * can safely address 10 deg of version * bone graft - technically demanding and not reproducible * insufficient bone stalk * corrections \> 15 deg * deficiency after eccentric reaming * Risks - nonunion, dislodgement * Metal augments * For the dysplastic glenoid * the posterior structures are hyperplastic * there is no posterior subluxation as there is with a biconcave glenoid * safe to correct only slightly or leave them where they are or they will loose internal rotation

Answer 36

* **Major criteria** * Draining sinus tract * Identical organisms isolated by culture from at least 2 separate tissue or fluid samples * **Minor criteria** * Elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration * Elevated synovial white blood cell count * Elevated synovial neutrophil percentage (PMN%) * Presence of purulence in affected joint * A single positive culture of tissue or fluid * \>5 neutrophils per high-power field in 5 high-power fields of tissue histology

Answer 37

* Have a high suspicion * Common organisms * P. Acnes * S. Aureus * Staph epideridus * Blood work - elevated ESR, CRP * May or may not be evidence on XR * Bone scan is not useful * Image guided joint aspiration * ask to hold cultures for 21 days * no good recommendations for elevated WBC and PMN * Intra-operative * increased risk with cloudy fluid and membrane formation * send synovial tissue and fluid cultures * Fresh frozen section: \> 5 neutrophils in 5 high powered feild * Ways to increase chance of finding infection * don't give antibiotics before OR * multiple deep cultures * hold cultures for 21 days * implant sonification and culture * PCR of synovial fluid

Answer 38

* Risk factors * low immunity in joints, high nutrients in synovial fluid * sebaceous glands * close proximity to axilla * medial and patient factors * **ID Consult** * ****Start IV antibiotics * PenG * then Vanco is second choice * **Debridement with hardware retention and antibiotic suppression** * only if recognized \< 3 weeks * 50% failure ratae * **Single stage prosthesis exchange** * ****Not in favour, but there have been good results * **Two-stage prosthesis exchange** * implant extraction * humeral split osteotomy * cortical window * fix with circlage wires * ****prefabricated spacer, or make a spacer out of a stimen pin and a chest tube * can be used to bridge fracture as well * then convert to TSA if possible or rTSA if there has been severe supeiror bone loss and comprimise of the RC, or a hemiarthroplasty due to increased risk of re-infection with total * IV antibiotics, antibiotic holiday when ESR/CRP normalize, if remain low then perform second stage * **Arthrodesis or resection arthroplasty** * ****severely deficient bone * very poor results compare to prosthesis reimplantation with no imporvement in recurrence

Answer 39

* **Wright and coland** * ****A - above the prosthesis * B - at the tip of the prosthesis * C - below the prosthesis

Answer 40

* **Non-operative** * C type fracture that can be maintained in a sugar tong * medical co-morbidities, active infection * **Components** * fracture displacement * location * stability of humeral component * \> 2mm lucency around the stem * change in stem position * **ORIF - plates, circlage wires** * stable component * displaced fracture * B type fracture * Nonunion of previous C type fracture treated non-op * agument with allograft strut * iliac crest graft in the nonunion site * **Revision long stem** * stem subsidence * cemented or uncemented ok * pass fracture by 2 cortical diameters * augment with plates, screws and circlage wires * **Be very cogniscent of the radial nerve at all times**

Answer 41

* sling for comfort * start PROM but limit ER to neutral and FF to 100deg * increase to AAROM and increase PROM at 6 weeks * active use of the shoulder isn't started until 12 weeks

Answer 42

* assess instability and issues with soft tissues * if you just replace the component it will probably get loose again * take it out * ream * graft * rTSA * solves the problem of soft tissue balancing and instability * technically demanding and high rate of complications

Answer 43

* History * indication for index procedure * complicance with post-op rehab * history of RC tear * pain free period * instability, clunking, stiffness, signs of infection * numbness or other neurologial deficiet * Physical * scars, atrophy of deltoid or RC * palpate boney prominences * PROM, AROM * assess RC function * full neurovascular exam * Studies * ESR, CRP * aspiration - keep for 21 days * Plain XR - AP, lateral, Axillary * CT - assess glenoid, version of the humerus, loosening of components * EMG if concerns * MRI with modified sequences * Indications for revision * Goals * primarily pain control * function, strength are secondary * infection * malpositioning * loosening * adhesions * contractures

Answer 44

* Always rule out infection * **Glenoid loosening** * removal of glenoid * structural iliac crest graft * the later can revise to TSA or rTSA * **Stiffness** * try PT for at least 6 months * Open threw deltopec * release deltoid adhesions being careful of axillary nerve, release pec * biceps release * release the subscap - can consider medial transfer or Z-lengthening * capsule release with arm in 60 abduction and 30 ER * assess components for overstuffing * Post-op * limt ER for subscap repair * supervised PT program * consider scalene block for adequate pain control to encourage ROM * **Unstable arthroplasty** * humeral head should translate \< 50% in any direction * ****_Imablance in soft tissue stabilizers_ * tight anterior capsule can be relased, capsule, subscap, pec major * posterior capsulorraphy * _Rotator cuff deficieny_ * __more common in RA * will cause superior migration, early loosening, decrease in function and pain * treated with * expectant managment (usually fails) * surgical repair * latissiumus dorsi transfer * revision to rTSA * _subscapularis failure_ * __should be fixed early * if you can't repair it * pec major transfer * allograft * **Neurological injury** * usually axillary, less commonly MC * more common in rTSA * ****invovle peripheral nerve surgery * EMG at 6 weeks and 3 months * PT and ROM

Answer 45

**Type I:** Positive cultures at time of revision surgery—directed culture-specific antibiotic treatment for an undetermined period of time **Type II:** Acute infection within 30 days after surgery—surgical debridement and irrigation with retention of prosthetic components **Type III:** Acute hematogenous infection more than 30 days after surgery—either surgical debridement and irrigation with retention of implants versus explantation and two-stage revision arthroplasty **Type IV:** Chronic infection—surgical debridement and irrigation, antibiotic spacer placement, IV antibiotics for at least 8 weeks, and staged reimplantation of components after negative intraoperative cultures

Answer 46

* **Indications** * stabilization of paralytic disorders * brachial plexus palsy * irreparable deltoid and rotator cuff deficiency with arthropathy * salvage of a failed total shoulder arthroplasty * reconstruction after tumor resection * painful ankylosis after chronic infection * recurrent shoulder instability which has failed previous repair attempts * paralytic disorders in infancy * **Contraindications** * ipsilateral elbow arthrodesis * contralateral shoulder arthrodesis * lack of functional scapulothoracic motion * trapezius, levator scapulae, or serratus anterior paralysis * Charcot arthropathy * elderly patients * progressive neurologic disease

Answer 47

* **Approach** * S-shaped skin incision beginning over the scapular spine, traversing anteriorly over the acromion, and extending down the anterolateral aspect of the arm * **Fusion position** * think "30°-30°-30°" * **Technique** * rotator cuff is resected from the proximal humerus and the biceps tendon is tenotomize * glenoid and humeral head articular surfaces and the undersurface of the acromion are decorticated * arm is placed into the position of fusion _(30°-30°-30°_) * _a 10-hole, 4.5 mm pelvic reconstruction plate_ is contoured along the spine of the scapula, over the acromion, and down the shaft of the humerus * compression screws are placed through the plate across the glenohumeral articular surface into the glenoid fossa * the plate is anchored to the scapular spine with a screw into the base of the coracoid * **Postoperative care** * a thermoplastic orthosis is applied the day after surgery and is maintained for 6 weeks * at 6 weeks, may transition to a sling if there are no radiographic signs of loosening * at 3 months, mobilization exercises and thoracoscapular strengthening are commenced if no radiographic signs of loosening are present * expected recovery period is 6-12 months

Answer 48

* **Type I** * Labral and biceps fraying, anchor intact * 11% * **Type II** * Labral fraying with detached biceps tendon anchor * 41% * **Type III** * Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear) * 33% * **Type IV** * Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear) * 15% * **Type V** * SLAP lesion and anterior labral tear (Bankart lesion) * **Type VI** * Superior flap tear * **Type VII** * SLAP lesion with capsular injury

Answer 49

* Physical * may see infraspinatous wasting * weankness in ER * yeargson, speed, O'brien * Imaging * MRI or MRarthrogram * will see SLAP lesion with spinoglenoid cyst * Arthrscopy * can assess with peel-back test

Answer 50

* **week 1-4** * sling with passive forward elevation. Avoid extremes of abduction and external rotation * passive and active assisted flexion in the scapular plane * **week 4-6** * progress to active ROM, isometrics * **week 6-12** * functional exercise and light strengthening * **week 12+** * advance strength and ROM, sport-specifics * typical return to sport around 6 months

Upper Extremity Flashcards

(74 cards)