ORTHOPEDIC MCQS ONLINE OB SHOULDER AND ELBOW 1A 

©

 

1. A 24-year-old avid volleyball player has noted gradual onset of shoulder fatigue and weakness limiting his game. Radiographs done by his primary care physician were normal and he has failed to improve with 6 weeks of physical therapy. Given the MRI image shown in Figure A, this patients physical exam may reveal weakness with which of the following actions?

    

    

    

    

    

   Adduction Internal rotation

    

    

    

    

   Abduction and external rotation Abduction

    

    

   External rotation

   CORRECT ANSWER: 3

   The MRI demonstrates of a ganglion cyst within the suprascapular notch, leading to atrophy of both the supraspinatus and infraspinatus. Thus, the patient would have weakness with both abduction and external rotation.

   Extrinsic compression or traction on the suprascapular nerve can result in suprascapular neuropathy. Compression of the nerve may occur at two distinct locations: the suprascapular notch and the spinoglenoid notch. Extrinsic compression of the suprascapular nerve by ganglion cysts can occur at the spinoglenoid notch or, less commonly, at the suprascapular notch. These cysts may originate from the transverse scapular ligament, the fibrous tissue of the scapula, or the glenohumeral joint.

   Mittal et al. reviewed the literature and found that the formation of ganglionic cysts in the spinoglenoid fossa occurs with cumulative trauma and leads to entrapment neuropathy of the suprascapular nerve and denervation of the infraspinatus muscle.

   Romeo et al. reported on various etiologies of suprascapular neuropathy including traction injury at the level of the transverse scapular ligament or the spinoglenoid ligament and direct trauma to the nerve. They noted that sports involving overhead motion, such as tennis, swimming, and weight lifting, may result in traction injury to the suprascapular nerve, leading to dysfunction. They also reported that the onset of weakness can be subtle and must be differentiated from cervical radiculopathy and degenerative disease of the shoulder.

   Figure A depicts a T2 coronal MRI of the shoulder with a cyst easily visualized occupying the suprascapular notch. Illustration A is an algorithm for the management of suprascapular neuropathy. Illustration B is a sagittal MRI from the same patient depicting the ganglion cyst within the suprascapular notch once again leading to atrophy of both the supraspinatus and infraspinatus (asterisks).

   Incorrect Answers:

   Answer 1&2: The suprascapular nerve does not innervate the muscles that function to adduct and internally rotate the shoulder.

   Answer 4&5: Because the suprascapular nerve is being compressed at the suprascapular notch, it will affect the function of both the infraspinatus and supraspinatus.

    

    

    

    

    

    

    

2. Which of the following best describes a Buford complex?

    

   Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior

    

    

    

    

   labrum labrum

   Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent

   anterosuperior labrum

    

    

   Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum

    

    

   Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum

   CORRECT ANSWER: 1

   A Buford complex, first described by Buford in 1994, is a normal anatomical variant seen in 1.5% of individuals and consists of a cord-like MGHL and absent anterosuperior labrum complex. The cord-like MGHL should not be repaired down to the glenoid as this will result in decreased postoperative range of motion.

   Rao et al demonstrated three distinct variations of the anterosuperior portion of the labrum with sublabral foramen being more prevalent than a Buford complex. These normal variants were in order of decreasing prevalence: (1) sublabral foramen with a cord-like MGHL (8%), (2) sublabral foramen (3%), and (3) Buford complex: an absence of labral tissue at the anterosuperior quadrant with a cord-like MGHL (1.5%).

   Steinbeck et al. inspected cadaver shoulders and found an absence of an MGHL occurred in 15% of shoulders and was associated with signs of pathologic instability, either Hill-Sachs or bony Bankart. Illustration A is an arthroscopic image of a Buford Complex, labeled "cord-like MGHL".

   Illustration V is a video that shows a diagnostic arthroscopy with a Buford complex.

    

    

    

    

3. A 78-year old female sustained a 4-part proximal humerus fracture on her dominant side 2 days ago and undergoes a shoulder hemiarthroplasty. Intraoperatively, the lesser tuberosity reduction was difficult and placed too close to the greater tuberosity, which was anatomic. What post-operative problem is likely to result due to the position of the lesser tuberosity?

    

    

    

    

    

    

    

    

    

   external rotation deficit internal rotation deficit multi-directional instability forward elevation weakness elbow flexion weakness

   CORRECT ANSWER: 1

   Placing the lesser tuberosity in a more lateral position will increase tension on the subscapularis and likely lead to a deficit in external rotation. Variable outcomes in the prosthetic reconstruction of 4-part humerus fractures often can be attributed to inconsistent and nonanatomic tuberosity placement.

   Frankle et al (2001) examined the effects of tuberosity malposition in proximal humeral reconstruction after 4 part fractures and found out that there was significant alteration in external rotation kinematics and torque requirements. Failure to properly position tuberosity fragments in the horizontal plane may result in insurmountable postoperative motion restriction.

    

    

4. A 23-year-old professional pitcher complains of posterior shoulder pain. Physical exam is notable for scapular dyskinesis. No intraarticular pathology is found on shoulder MRI. Which of the following should be emphasized in the initial stages of rehabilitation?

    

    

    

    

    

   Isometric shoulder exercises Isokinetic shoulder exercises Closed chain shoulder exercises

    

    

    

    

   Coordination of scapular motion with trunk and hip movements Axial loading shoulder exercises

   CORRECT ANSWER: 4

   Scapular dyskinesis is an alteration in the normal motion of the scapula during coordinated scapulohumeral movements. It occurs as a sequela of prior shoulder injury, especially injuries disrupting the activation patterns of scapular stabilizing muscles. Kibler et. al outlined a rehabilitation protocol to treat scapular dyskinesis. The principle is to treat the problem from proximal to distal. The first stage involves attaining full motion of the scapula and coordinating the scapula with trunk and hip motions. Once this has been achieved, the second stage involves strengthening the scapular musculature. As scapular control is attained, exercises are introduced that place emphasis on the shoulder and arm beginning with flexibility and closed-chain strengthening, and eventually working up to sport-specific functions. Progress is determined by functional improvement rather than a strict time table. Kibler et al outline the presentation, evaluation, and treatment for scapular dyskinesis in the JAAOS review article. They specifically discuss the acute, recovery, and maintenance phases of rehabilitation.

    

    

5. A patient is scheduled to undergo arthroscopy for a SLAP tear of his shoulder. Based on the sagittal images of the right shoulder MRI shown in Figure A, what additional physical exam finding is the patient likely to display?

    

    

    

    

    

    

    

    

    

    

    

   Weakness in forward elevation Weakness in internal rotation Weakness in external rotation Positive impingement maneuver Scapular winging

   CORRECT ANSWER: 3

   The MRI shows a cyst in the spinoglenoid notch, which is important to differentiate from a cyst in the suprascapular notch.

   A suprascapular cyst can impinge upon the suprascapular nerve prior to innervation of the supraspinatus and infraspinatus muscle, leading to weakness in both muscles. Prolonged impingement on the suprascapular nerve by a spinoglenoid cyst can result in atrophy of the

   infraspinatus muscles. This would show up as weakness in external rotation on exam. These cysts are associated with SLAP lesions and per literature are formed by a one-way valve effect, where synovial fluid can exit the joint into the cyst but not drain spontaneously.

   Chen et al describe 3 cases in which preoperative and postoperative EMG's and MRI imaging documented cyst resolution and return of suprascapular nerve function after arthroscopic spinoglenoid cyst excision and labral repair.

    

    

   Figure A and Illustration A shows a cyst in the spinoglenoid notch, where it may impinge on the suprascapular nerve as it travels around the glenoid and under the spine of the scapula on its way to innervate the infraspinatus muscle. Illustration B shows the anatomic locations of the suprascapular notch and the spinoglenoid notch and the course of the suprascapular nerve.

    

    

    

    

    

6. Arthroscopic subacromial decompression with acromioplasty has been shown to yield lower subjective satisfaction scores in patients with which of the following preoperative factors?

 

 

 

Dominant arm involvement Males

 

 

 

 

Workers' compensation Smokers

 

 

Age <60

CORRECT ANSWER: 3

 

 

 

 

reported significantly decreased satisfaction postoperatively compared to the rest of the cohort. The most recent article reported similar scores, but longer time to return to work.

 

7) A 65-year-old right-hand-dominant man reports acute right shoulder pain and inability to lift his arm overhead after a glenohumeral dislocation while skiing 2 weeks ago. Physical exam reveals active forward elevation to 30 degrees and 3/5 external rotation strength, pain with motion, and intact lateral arm sensation. An MRI is contraindicated due to a pacemaker, and therefore an arthrogram is performed and shown in Figure A. What is the most appropriate treatment option?

 

 

 

 

 

 

 

 

 

 

Shoulder hemiarthroplasty Rotator cuff repair Proximal humerus ORIF Total shoulder arthroplasty Sling immobilization

CORRECT ANSWER: 2

The clinical presentation is consistent with an acute rotator cuff tear following a shoulder dislocation, so the most appropriate treatment is a rotator cuff repair.

A shoulder dislocation in a patient >40 years-old commonly results in a rotator cuff tear. An arthogram may be helpful to confirm the diagnosis when an MRI is contraindicated. The arthrogram shows extravasation of the dye into the subacromial space with no evidence of arthritis. A rotator cuff tear allows the dye to leak into the subacromial space, whereas in a normal MRI arthrogram the dye is contained within the joint capsule (Illustration A).

Craig et al described the geyser sign (Illustration B), which is when dye from a shoulder arthrogram leaks into the subacromial space as well as into the AC joint. This is indicative of a long-standing full-thickness RCT that has now involved the AC joint.

Jensen et al review the pathogenesis of rotator cuff arthropathy which they define as the end point in the continuum of severe degenerative changes in the glenohumeral joint.

 

 

 

 

 

 

 

1. A 22-year-old minor league baseball pitcher is being treated for shoulder pain with a focused rehabilitation program. Figures A and B display rehabilitation manuevers that are critical in the treatment of his shoulder pathology. What is the most likely diagnosis in this athlete?

    

    

    

    

    

    

    

    

    

    

   Long head of the biceps tendonosis Glenohumeral internal rotation deficit (GIRD ) Subscapularis rupture

    

    

    

    

   Superior labral anterior posterior (SLAP) tear Bankart lesion

   CORRECT ANSWER: 2

   Figure A shows a sleeper stretch and Figure B shows a prone internal rotation stretch with scapular stabilization which are both forms of posterior capsular stretching. Baseball pitchers often have excessive external rotation and diminished internal rotation on their throwing shoulder. A rehabilitation program that includes posterior capsular stretching is essential for the treatment of GIRD.

   According to the review article by Braun et al, GIRD is a posterior shift in the total arc of motion and is thought to be a physiological adaptation of the shoulder joint to throwing. The treatment of loss of internal rotation is stretching of the posterior capsule.

   The Level 3 article by Crockett et al reviewed shoulder CT scans and shoulder range of motion in 25 pitchers and 25 non-throwers. The pitcher group demonstrated a significant increase in humeral head retroversion by CT scan, external rotation at 90°, external rotation in the scapular plane, and total range of motion compared to the non-pitchers.

    

    

2. A 34-year-old carpenter has left shoulder pain for the past 3 months following a fall from a ladder. Figure A displays a coronal T2 MR image. Which of the following diagnoses most appropriately describes this patient's lesion?

    

    

    

    

    

    

    

    

    

    

    

   Anterior labral periosteal sleeve avulsion (ALPSA ) Partial articular surface tendon avulsion (PASTA ) Humeral avulsion of the glenohumeral ligament (HAGL ) Superior labral anterior to posterior tear (SLAP ) Glenolabral articular disruption (GLAD) lesion

   CORRECT ANSWER: 2

   The MR image shown in Figure A demonstrates a partial articular surface tendon avulsion (PASTA) lesion of the supraspinatus. PASTA lesions can be difficult to diagnose and intraarticular contrast can help to delineate the pathology as seen in Illustration A. Disrupted anterior scapular periosteum differentiates a Bankart lesion from its variants where periosteum remains intact. An ALPSA lesion (Illustration B) is where the labral-ligamentous complex is displaced medially and shifted inferiorly, rolling up on itself underneath intact periosteum. A GLAD lesion (Illustration C) is a tear of the anterior inferior labrum (nondisplaced) with avulsion of the adjacent glenoid cartilage. A HAGL lesion (Illustration D) is where the inferior glenohumeral ligament avulses from the inferior humeral neck. Superior labral tears anterior to posterior to the biceps root are known as SLAP tears (Illustration E) .

   Gartsman et al provide Level 4 evidence of 85 shoulders taken to the OR for impingement symptoms and found a partial tear of the rotator cuff. These shoulders were treated with debridement of the tear and arthroscopic subacromial decompression and had greater than 80% success rate.

   The study by Snyder et al reviews 31 patients with partial thickness rotator cuff tears that were treated by arthroscopic debridement of the lesion. They concluded that 84% of the patients had satisfactory results.

    

    

    

    

    

    

    

    

    

    

3. While recent studies have failed to demonstrate a significant clinical difference, proximal biceps tenodesis compared to tenotomy is felt to possibly result in a lower incidence of which of the following? Arm cramping

    

    

   Elbow flexion weakness

    

    

    

    

    

    

   Elbow stiffness Shoulder weakness Shoulder stiffness

   CORRECT ANSWER: 1

   Concern for cosmetic defor

   argument against performing tenotomy in the past. The long head of the biceps tendon has been implicated as a common source of anterior shoulder pain. Surgical options to treat it include biceps tenodesis by various methods and intraarticular biceps tendon release- tenotomy. It is felt by some surgeons that a tenodesis may decrease subjective arm cramping and improve cosmesis. Of note, recent studies have failed to show a significant difference between the two groups. Osbahr et al retrospectively looked at their patients who had undergone either tenotomy or tenodesis and found non statistically significant differences. The patient were non randomized to treatment groups and therefore selection bias prohibits definitive conclusions.

    

   Frost et al performed a comprehensive review of the literature comparing the outcomes of tenotony and tenodesis, and noted that the studies were predominantly low quality. They concluded that there is a lack of quality evidence to advocate one technique over the other.

    

    

4. What is the preferred treatment for a symptomatic acute acromioclavicular separation where there is a 20% increase in the coracoclavicular distance on AP radiograph compared to the opposite uninjured side?

    

    

    

   Anatomic coracoclavicular ligament reconstruction Acute repair of acromioclavicular capsule

    

    

   Sling followed by early physical therapy

    

    

    

    

   Reduction and retrograde pinning of the acromioclavicular joint Distal clavicle excision

   CORRECT ANSWER: 3

   A 20% increase in the coracoclavicular distance on AP radiograph compared to the uninjured side would classify this AC separation as a Type II based on the Rockwood classification. The preferred treatment for a type II AC separation is non-operative with a sling and early physical therapy. The reference by Mouhsine et al outlines the typically successful outcomes of non-operative treatment of type I and II AC separations. They found good results but many patients (48%) remained symptomatic after 6 years with activity related pain or AC tenderness and 84% of these patients had radiographic evidence of AC degeneration, distal clavicle lysis, or CC ligament ossification.

   The reference by Clarke and McCann reviews the diagnosis and treatment of AC separations. They argue Type I and Type II AC separations are treated nonoperatively, while types IV-VI are nearly always treated surgically. The treatment of Type III remains controversial.

   Illustration A depicts the different types of AC separations.

    

    

    

    

5. A 62-year-old female presents with chronic shoulder pain. She denies any recent or remote history of trauma or infection. A radiograph is provided in Figure A. Which of the following is the most common cause of her findings?

    

    

    

    

    

    

    

    

    

    

    

   Diabetes Syphilis Alcoholism Syringomyelia Uremia

   CORRECT ANSWER: 4

   The clinical presentation is consistent with Charcot neuroarthropathy of the shoulder. The most common cause of neuropathic arthropathy of the shoulder is syringomyelia, although chronic alcoholism and diabetes have also been reported.

   Workup for neuropathic arthropathy of the shoulder includes magnetic resonance images of the cervical spine, to look for a syrinx of the central cord.

   Hatzis et al retrospectively reviewed a series of patients with neuropathic arthropathy of the shoulder. The etiology of the neuropathic condition was most commonly syringomyelia. They reported that the diagnosis is often missed, and inappropriate surgeries were frequently performed for this etiology.

   Clayton et al also reviewed Charcot arthropathy of the shoulder and concluded that although rare, diabetes mellitus should always be ruled out as a cause for this disorder. They report that treatment should not be different with diabetes as the etiology.

   Figure A shows a proximal humerus with significant destruction and fragmentation, consistent with Charcot neuroarthropathy Incorrect Answers:

   Answer 1: Diabetes is a documented cause of Charcot neuroarthropathy of the shoulder, but is less common than Syringomyelia.

   Answer 2: Syphilis is no longer the most common cause of these findings. Answer 3: Alcoholism is a documented cause of Charcot neuroarthropathy of the shoulder, but is less common than Syringomyelia.

   Answer 5: There is no documented association between Charcot neuroarthropathy and uremia.

    

    

6. Triceps ruptures are associated with all of the following EXCEPT?

    

   Anabolic steroid use

    

    

    

    

    

    

    

    

   Local corticosteroid injection Renal osteodystrophy Fluoroquinolone use Creatine supplement use

   CORRECT ANSWER: 5

   Creatine supplement use has not been associated with triceps rupture. Triceps ruptures have been reported in weightlifters who bench press heavy weight, use anabolic steroids, have a history of local steroid injections to the triceps tendon, patients with renal osteodystrophy, and with use of fluoroquinolone antibiotics.

   Rettig reviews the risk factors associated with triceps rupture as described above.

   Sollender at al and Stannard et al presented cases of triceps tendon ruptures in weightlifters who used anabolic steroids or had numerous local steroid injections.

   Khaliq and Zhanell reviewed fluoroquinolone tendon injury and reported two cases of triceps rupture.

    

    

7. A 72-year-old male who underwent right total shoulder arthroplasty 8 months ago is unable to lift his right hand off his back and has weakness with internal rotation. What is the most likely diagnosis?

    

   Brachial neuritis

    

    

    

    

    

    

    

    

   Long head of biceps rupture Subscapularis insufficiency Subscapularis nerve palsy Standard postoperative recovery

   CORRECT ANSWER: 3

   The patient is unable to internally rotate and has a positive lift-off test ( inability to lift off hand from behind back), all significant for subscapularis insufficiency which may happen after any anterior approach to the shoulder with takedown of the subscapularis. Subscapular insufficiency may occur with failure of tendon repair or permanent changes to the subscapularis muscle. Clinical findings include internal rotation weakness, increased passive external rotation, weakness to belly press, and an abnormal subscapularis lift-off test (Video A demonstrates lift-off test). Scheibel et al reports on 25 patients (primary and revision) who underwent open shoulder stabilization with an inverted L-shaped tenotomy approach which lead to atrophy and fatty

   infiltration on MRI resulting in postoperative subscapularis muscle insufficiency.

    

    

8. Which of the following is a primary restraint of anterior and posterior humeral translation at the position of a patient's right shoulder as shown in Figure A?

    

    

    

    

    

    

    

    

    

   Inferior glenohumeral ligament (IGHL ) Middle glenohumeral ligament (MGHL ) Superior glenohumeral ligament (SGHL ) Coracohumeral ligament (CHL ) Coracoacromial ligament (CA )

   CORRECT ANSWER: 2

   Figure A shows a shoulder in 45 degrees of abduction and 45 degrees of external rotation. The MGHL restrains anterior and posterior translation in the midrange of abduction. The CHL limits inferior translation and external rotation when then arm is adducted and limits posterior translation when the arm is flexed, adducted, and internal rotation. The SGHL also restrains inferior translation and external rotation of the adducted shoulder. The IGHL has an anterior band that is the primary restraint to anterior translation at 90 degrees of shoulder abduction. It also has a posterior band to limit posterior translation. The CA ligament prevents superior head migration in rotator cuff deficient shoulders.

   The study by Kuhn et al was a cadaveric study of 20 shoulder specimens mounted in a testing apparatus to simulate the thrower's late-cocking position. They found that cutting the entire inferior glenohumeral ligament resulted in the greatest increase in external rotation (approximately 10 degrees).

    

    

9. Which of the following is considered the primary static restraint to anterior glenohumeral translation with the arm in 90 degrees of abduction?

    

    

    

   Shape of the bony articulation Negative intra-articular pressure

    

    

    

    

    

    

   Superior gleno-humeral ligament complex Middle gleno-humeral ligament complex Inferior gleno-humeral ligament complex

   CORRECT ANSWER: 5

   The geometry of the bony articulation is inherently unstable. The rotator cuff is a dynamic stabilizer and the capsulolabral tissues are considered static stabilizers. With the arm at 90 degrees abduction, the anterior band of the inferior gleno-humeral ligament complex is the primary static stabilizer to anterior translation. The middle (MGHL) resists anterior translation at 45 degrees of abduction. The superior (SGHL) resists inferior translation with the arm at one's side.

   O'Brien et al. describe the functional anatomy of the inferior gleno-humeral complex based on a series of cadaveric dissections. They note that its orientation and design support the functional concept of this single structure as an important anterior and posterior stabilizer of the shoulder joint. The Burra paper is a review of acute upper extremity instability in athletes.

    

    

10. A 21-year-old male who is training to become a professional mixed martial artist complains of weakness with forward flexion of the right arm. Four months ago, he sustained several blows and kicks to his right upper extremity, torso, and flank during consecutive training sessions. Physical exam shows the deformity shown in Figure A. Which of the following muscles labeled in Figure B is most likely deficient and leading to his symptoms?

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    A B C D E

    CORRECT ANSWER: 4

    The patients presentation is consistent with medial scapular winging, which is caused by a long thoracic nerve palsy and serratus anterior muscle deficiency.

    The serratus anterior muscle is shown with the letter D in Figure B.

    The serratus anterior muscle draws the scapula forward and abducts the scapula. Medial scapular winging is a result of serratus anterior weakness and can be a result of nerve palsy, direct-blow trauma (most likely the case in this patient's presentation), microtrauma-induced strain, fatigue from repetitive tensile use, or muscle inhibition secondary to underlying glenohumeral pathology. Kibler et al (2003) notes that most of the abnormalities in scapular motion and position can be treated by physical therapy to relieve symptoms and to reestablish strength and activation patterns. Kibler et al (2002) tested the inter/intrarater reliabilities of physicians and physical therapists detecting the presence of scapular dyskinesis in 26 videotaped subjects. They concluded that abnormal shoulder motion could be detected after appropriate education.

    Incorrect Answers:

    Answer 1: A - Trapezius is the antagonist to serratus anterior, and when unopposed causes the scapula to be pulled medially.

    Answer 2: B - Teres major

    Answer 3: C - Latissimus Answer 5: E - Infraspinatus

     

     

11. A patient develops shoulder dysfunction and is noted to have medial winging of the scapula. If the EMG shows an abnormaility, which nerve is most likely to be involved?

     

     

     

     

     

    Suprascapular Axillary Long thoracic

     

     

     

     

    Thoracodorsal Radial

    CORRECT ANSWER: 3

    Medial scapular winging is usually due to loss of serratus anterior function due to long thoracic nerve palsy.

    Injury to the long thoracic nerve can occur during repetitive trauma, penetrating trauma, surgery, prolonged pressure due to positioning, or inflammatory processes. This results in superior elevation and medial translation of the scapula, with medial rotation of the inferior pole due to loss of serratus anterior muscle function. The patient will develop pain due to compensation by other periscapular muscles, with impaired arm elevation. The diagnosis of long thoracic nerve can be confirmed with EMG, with serial examinations every 3 months to follow recovery, which occurs in most cases within 1 year depending on etiology. For those patients with symptomatic serratus winging for longer than 1 year with EMG evidence of denervation, surgical options such as scapulothoracic fusion, fascial sling suspension, or muscle transfer can be considered. Kuhn et review different causes of scapular winging. They classify the condition as primary, secondary, or voluntary.

    Primary scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial conditions and resolves after the primary pathologic condition has been addressed. Voluntary scapular winging is not caused by an anatomic disorder and may be associated with underlying psychological issues.

     

     

12. A 47-year-old male with a history of a Putti-Platt procedure 20 years ago presents with right shoulder pain with decreased range-ofmotion. Radiograph is shown in Figure A. What is the most accurate diagnosis?

     

     

     

    Primary osteoarthritis

     

     

     

     

    Post-capsulorrhaphy arthropathy Post-traumatic arthritis

     

     

     

     

    Arthritis from poor placement of coracoid transfer Avascular necrosis

    CORRECT ANSWER: 2

    With a history of a Putti-Platt procedure with the radiograph, the patient most likely has postcapsulorrhaphy arthropathy.

    Post-stabilization procedure arthritis is thought to occur due to changes in contact loading in the shoulder joint due to fixing the joint in an incongruent posistion. It can be severe and debilitating,

    and lead to arthroplasty as a salvage procedure. The Putti-Platt procedure involves a division of the subscapularis tendon and anterior capsule, and realignment of the lateral tendon stump and capsule sewn into the anterior glenoid neck capsular insertion. The "pants-over-vest" style of repair is then finished by sewing the medial tendon stump into the tuberosity, so that external rotation is significantly limited by the soft tissue imbrication. There is no coracoid transfer for this stabilization procedure.

    Bigliani et al. reported on a series of similar patients who developed arthritis following surgery for recurrent glenohumeral dislocation. Authors have theorized that instability repair may excessively tighten the joint in one direction and cause a fixed subluxation in the direction opposite from the side of repair, leading to severe degenerative arthritis due to inappropriate contact loading. 77% of patients following arthroplasty after post-capsulorrhaphy arthropathy had an excellent or satisfactory outcome, with improved pain and range of motion.

    Figure A demonstrates severe osteoarthrosis of the affected shoulder, with significant joint space narrowing, periarticular osteophyte formation, and subchondral sclerosis.

    Incorrect Answers:

    Answers 1, 3, 4, 5: While all of these choices can lead to end-stage arthritis and indications for shoulder arthroplasty, the history given in this question stem indicates Answer 2 as the underlying diagnosis. Of course, the capsulorrhaphy may have been performed for traumatic dislocation, but the best answer choice for this stem is Answer 2.

     

     

13. A 25-year-old volleyball player has recurrent right shoulder pain. On exam she has right shoulder weakness to external rotation with her arm at her side and atrophy below the scapular spine. There is no external rotation lag sign. Jobe drop arm and hornblower's tests are negative. The O'Brien's active compression test is positive. What will most likely be found on MRI of her shoulder?

     

     

     

     

     

    Partial articular sided tear of the infraspinatus Partial articular sided tear of the supraspinatus Full thickness tear of the infraspinatus

     

     

     

     

    Inferior labral tear with quadrangular space cyst SLAP tear and spinoglenoid notch cyst

    CORRECT ANSWER: 5

    This is a classic case of suprascapular nerve impingment at the spinoglenoid notch, likely from a cyst associated with a posterior SLAP tear. Compression of the suprascapular nerve at the spinoglenoid notch causes isolated infraspinatus weakness while compression at the suprascapular notch would affect both the supraspinatus and infraspinatus. A posterior SLAP tear is suspected with a positive O'Brien's active compression test. The labral tear can allow cyst development in the spinoglenoid notch. Jobe drop arm test is abnormal with supraspinatus weakness and hornblower's test is abnormal with teres minor weakness.

    Thompson et al first described the findings of suprascapular nerve entrapment by a spinoglenoid notch cyst.

    Fehrman et al confirmed six cases of these cysts associated with posterior capsulolabral injuries. The article by Piasecki et al reviews the diagnosis and treatment of suprascapular neuropathy.

    Illustration A shows a typical appearance of a spinoglenoid cyst on MRI. Illustration B demonstrates O'Brien's active compression test whereby resisted arm flexion with the arm in internal rotation causes pain and external rotation relieves pain.

     

     

     

     

14. A 42-year-old male has a suspected distal biceps rupture with a tendon that can be palpated but is painful during the hook test examination. Which of the following is the most appropriate next step?

     

    Operative exploration of distal biceps tendon

     

     

     

     

    Immobilization for three weeks followed by repeat physical examination Early physical therapy with emphasis on ROM and strengthening

     

     

     

     

    CT scan MRI scan

    CORRECT ANSWER: 5

    It is important to distinguish between complete and partial tears as it guides treatment decisions. Classic physical exam findings of complete tears include: antecubital pain and ecchymosis, nonpalpable distal biceps tendon (abnormal hook test), proximal retraction of the biceps muscle, and weakness with supination and flexion. A partial tear often has a normal hook test but has pain with the examination. An MRI is most appropriate for confirmation of a partial distal biceps rupture, while an MRI is not always required for a complete tear if the exam is conclusive.

    The reference by Vardakas et al reports a series of patients initially treated with conservative management for their partial biceps tendon tears. They were all then treated with operative fixation secondary to recalcitrant pain. They note significant improvement in pain at an average of 31 months in all 7 patients without any complications noted.

     

     

15. A 50-year-old wheelchair-bound male with a history of traumatic spinal cord injury presents with 6 months of progressive, painless left shoulder weakness and decreased range of motion. He is afebrile and CBC, ESR, and C-reactive protein levels are normal. A radiograph is shown in Figure A. Early management should include:

     

     

     

     

     

    HIV testing cervical spine MRI

     

     

     

     

     

     

    repeat ESR, C-reactive protein, CBC emergent open reduction and internal fixation emergent irrigation and drainage

    CORRECT ANSWER: 2

    This patient has a history of spinal cord injury and presents with an upper extremity neuropathic arthropathy, so a syrinx is highly suspected. Figure A demonstrates a Charcot left shoulder. Hatzis et al demonstrated that of 6 patients with Charcot shoulder, 5 of the 6 patients were found to have syrinx on MRI of the spine as the underlying cause. Therefore, all patients with shoulder neuropathic arthropathy should receive an MRI of the cervical spine.

    As discussed by Guille et al., other causes of neuroarthropathy of the shoulder include Chiari malformation, syphilis and diabetes. They reported on a rare case of Charcot shoulder neuroarthropathy from familial sensory neuropathy.

     

     

16. When performing an arthroscopic distal clavicle excision for acromioclavicular joint arthrosis, which of the following structures must be preserved to prevent post-operative anteroposterior instability of the clavicle?

     

    Trapezoid ligament

     

     

     

     

     

     

    Anterior and inferior acromioclavicular joint capsule Superior and posterior acromioclavicular joint capsule Coracohumeral ligament

     

     

    Conoid ligament

    CORRECT ANSWER: 3

    Numerous biomechanical studies have shown that the primary restraint to anteroposterior translation of the clavicle is the ligamentous thickenings of the acromioclavicular joint capsule. Debski et al showed in one such study that the strongest of these ligaments is the superior one, verifying the findings of several other authors. They reported that the superior ligament supplies around 50% of the strength against anteroposterior translation, and it is thickest in its posterior aspect. Additionally, the posterior AC ligament adds an additional 25% of the overall strength. For this reason, these ligaments should be preserved when performing a distal clavicle resection. The length of distal clavicle that can be taken and still preserve stability of the joint is highly debated in the literature. The conoid and trapezoid ligaments are the primary restraints to vertical translation at the AC joint. Renfree and Wright review the published anatomic findings around the AC and SC joints, and come to similar conclusions as above.

     

     

17. A 32-year-old overhead athlete catches himself with his right hand while slipping on ice and injures his right shoulder. He fails to improve with therapy, anti-inflammatory medicines, and rest. His MRI is demonstrated in Figure A. What is the most likely diagnosis?

     

     

     

    HAGL

     

     

     

     

    SLAP tear ALPSA

     

     

     

     

    Bankart Loose body

    CORRECT ANSWER: 2

    The T2 MRI image demonstrates a superior labral anterior to posterior tear ( SLAP tear), and also shows a partial articular sided tear of the supraspinatus tendon. The gold standard for diagnosis of a SLAP tear is arthroscopy. A study by Yoneda et al. demonstrated that the presence of a linear, high-tointermediate intensity area between the superior labrum and the glenoid rim on oblique coronal T2-weighted images had a sensitivity of 41%, a specificity of 86%, and an accuracy of 63% for diagnosing a SLAP tear. However, there have been recent concerns about the overdiagnosis and SLAP repairs, based on increased number of SLAP repairs in ABOS part II case logs, as presented at the AANA 2010 meeting. A HAGL lesion is a humeral avulsion of the anterior inferior glenohumeral ligament (Image in Illustration A). An ALPSA lesion is seen on an axial image and is an anterior labral periosteal sleeve avulsion characterized by the capsulolabralperiosteal complex peeling off the glenoid face and displacing medially on the glenoid neck. A Bankart lesion is an anterioinferior labral tear often caused by an anterior shoulder dislocation.

     

     

     

     

18. Resection of the coracoacromial ligament during shoulder arthroscopy results in which of the following?

     

     

     

     

     

    Increased glenohumeral joint translation Increased passive shoulder internal rotation Increased axillary recess volume

     

     

     

     

    Decreased acromioclavicular joint reactive forces Decreased resting tension in the long head of the biceps

    CORRECT ANSWER: 1

    The CA ligament provides a suspension function and restrains anterior translation through an interaction with the coracohumeral ligament. Resection of the coracoacromial ligament results in increased glenohumeral joint translation.

    Lee et al, in a cadaveric study, showed that at 0 degrees and 30 degrees of abduction, release of the coracoacromial (CA) ligament resulted in a significant increase in glenohumeral joint translations, in both the anterior and inferior directions. The authors state that caution should be exercised in the release of the coracoacromial ligament in those with rotator cuff pain associated with glenohumeral instability. This is especially crucial in patients who may later undergo shoulder arthroplasty, as anterior escape leads to significantly worse clinical outcomes.

    Illustration A shows the anatomy of the region, including the CA ligament. Illustration B is a radiograph showing anterosuperior escape after CA ligament resection.

     

     

     

     

     

     

     

19. An 18-year-old high school volleyball player is being treated for multidirectional instability of the right shoulder with a physical therapy program. She has intermittent pain and instability and episodic numbness and weakness in the ipsilateral hand. All of the following are characteristic features of a generalized connective tissue disorder EXCEPT:

     

    Elbow hyperextension of the left arm

     

     

     

     

     

     

    Left 5th finger passive extension beyond 90° Genu recurvatum of the bilateral knees Excessive supination of the left forearm

     

     

    Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand

    CORRECT ANSWER: 4

    Excessive supination of the left arm is not listed as part of the Beighton 9point scoring system for hypermobility. All of the other options are part of this scoring system, and a score of >6 is associated with connective tissue disorders such as Marfan's and Ehlers-Danlos Syndrome. The Level 5 review article by Schenk and Brems notes that generalized ligamentous laxity has been reported in 45% to 75% of patients who have undergone surgery for multidirectional (MDI) shoulder instability. Patients with MDI have pathologic laxity of the glenohumeral joint in more than one direction with at least one of those being inferior. The onset of symptoms is frequently atraumatic, and the chief complaint is often pain more than instability. Patients can experience concomitant recurrent, transient episodes of numbness, tingling, and weakness in the affected

    extremity. Most patients can be successfully treated nonoperatively with a specific exercise program. If a 6-month trial of nonoperative management fails, then surgical intervention with an inferior capsular shift can be performed.

     

     

20. A college baseball pitcher has posterior-superior and anterior pain in his throwing shoulder. On exam, he has a 30 degree loss of internal rotation on the affected side and a positive O'Brien's test. Radiographs and MRI are normal. While all of the following may be helpful, which of the following exercises should be emphasized most in this patient's rehabilitation program?

     

     

     

    Sleeper stretches, cross-body stretches, periscapular strengthening Sleeper stretches and subscapularis stengthening

     

     

     

     

     

     

    External rotation stretches with cuff strengthening External rotation stretches and periscapular strengthening Altering his arm slot and improving pitching mechanics

    CORRECT ANSWER: 1

    The clinical presentation is consistent with GIRD which is treated with aggressive rehabilitation consisting of posterior capsular and cuff stretching.

    GIRD (glenohumeral internal rotation deficit) is now commonly recognized in throwing shoulders. Posterior cuff and capsular tightness can cause decreased internal rotation which may cause pain and is implicated in SLAP and articularsided rotator cuff tears. Radiographs and MRI are often normal.

    Kibler et al reviews scapular dyskinesis and its relation to shoulder pain. They report treatment of scapular dyskinesis is directed at managing underlying causes and restoring normal scapular muscle activation patterns by kinetic chain-based rehabilitation protocols.

    Burkhart et al developed the acronym "SICK" to refer to the findings one sees in this syndrome (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement). This overuse muscular fatigue syndrome is yet another cause of shoulder pain in the throwing athlete.

     

     

21. A patient presents complaining of right shoulder pain and weakness following a neck exploration surgery. On exam, he is noted to have winging of the scapula. His EMG shows denervation of the trapezius muscle. This condition is best described as:

     

     

     

     

     

     

     

     

     

    Lateral winging due to spinal accesory nerve injury Medial winging due to spinal accesory nerve injury Lateral winging due to long thoracic nerve injury Medial winging due to long thoracic nerve injury Scapular dyskinesia due to cervical radiculopathy

    CORRECT ANSWER: 1

    The clinical presentation is consistent with lateral scapular winging due to iatrogenic injury to the spinal accessory nerve.

    Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. Causes include traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Serratus anterior paralysis, such as from the long thoracic nerve, results in medial winging of the scapula.

    This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective.

    The review by Kuhn et al. classifies scapular winging as primary, secondary, or voluntary. Primary scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial conditions and resolves after the primary pathologic condition has been addressed.

    Romero et al described the Eden-Lange procedure with lateral transfer of the levator scapulae and rhomboid muscles which can be helpful for lateral winging. They report satisfactory long-term results for the treatment of isolated paralysis of trapezius, but in the presence of an additional

    serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function.

    Levy et al describe a clinical forward elevation lag sign for trapezius palsy with resulting "Triangle sign" in the prone position which differentiates this from serratus winging.

     

     

22. Your partner performs distal clavicle excisions through an open approach while you prefer to use an arthroscopic approach. He notes that the literature shows both techniques have similar results with the exception of which of the following benefits of an arthroscopic approach?

     

     

     

    Ability to evaluate the glenohumeral joint Preservation of the coracoclavicular ligaments

     

     

     

     

    Preservation of the inferior acromioclavicular ligaments Lower complication rate

     

     

    Decreased surgical time

    CORRECT ANSWER: 1

    The arthroscopic approach with an initial diagnostic arthroscopy of the glenohumeral space prior to subacromial space is felt to be helpful in confirming the diagnosis and identifying other pathology. Berg et al. reviewed failures of open distal clavicle excision and found that 15 patients had a missed SLAP lesion. Fewer complications, lower infection rate, and decreased surgical time have not been documented in the literature.

    Lemos & Tolo reviewed complications resulting from treatment of AC joint pathology. The open technique can often miss other underlying pathology, such as rotator cuff and labral pathology, that may be associated with degenerative changes of the acromioclavicular joint. Therefore, they recommend that even if an open distal clavicle excision is the treatment of choice, an arthroscopic evaluation of the glenohumeral joint be performed at the same time.

     

     

23. A 60-year-old man has chronic shoulder pain and weakness. Radiographs show moderate glenohumeral arthritis and narrowing of the acromio-humeral distance. He is scheduled to undergo either hemiarthroplasty or total shoulder arthroplasty. His postoperative function will be most affected by which of the following factors?

     

    The integrity of the rotator cuff

     

     

     

     

    The integrity of the coracoacromial ligament The presence of glenoid wear

     

     

     

     

    The presence of an inferior head osteophyte The extent of AC joint arthritis

    CORRECT ANSWER: 1

    With conventional arthroplasty, the functional outcomes are dependent on the integrity of the rotator cuff. Narrowing of the acromio-humeral distance indicates superior migration of the humeral head which is often seen in cases of rotator cuff deficiency. Further imaging studies such as an MRI or CT arthrogram may be indicated to evaluate the status of the rotator cuff. If there is an irrepairable rotator cuff tear, total shoulder arthroplasty is contraindicated. In that case, the treatment options include hemiarthroplasty (with limited functional outcomes) or more recently, reverse total shoulder arthroplasty.

    Ianotti et al. evaluated the influence of several preoperative factors on the outcome of total shoulder arthroplasty and hemiarthroplasty. They performed concomitant rotator cuff repairs in 10% of the patients and found that repairable rotator cuff tears did not negatively affect the outcomes. Hettrich et al. reviewed the results of a large series of shoulder arthroplasty without glenoid resurfacing.

    They found the least functional improvements in those patients with rotator cuff arthropathy.

     

     

24. A 19-year-old college baseball player has posterior elbow pain despite non-operative treatment for 9 months. He developed acute worsening of pain and inability to throw. His imaging is shown in Figure A. What is the next most appropriate step in management?

 

Elbow arthroscopy

Open removal of osteophytes Ulnar nerve transposition

Internal fixation with a compression screw

Cast immobolization, followed by gradual return to strengthening program

CORRECT ANSWER: 4

Athletes may develop an olecranon stress fracture as seen in Figure A.

Initially, this is treated with rest from activity. If it does not go onto union, ORIF with a compression screw is indicated. This injury is commonly seen in baseball pitchers as well as other higher-level athletes and is thought of as an overuse-type injury. This is part of the valgusextension overload syndrome. Before it displaces, most of them are treated with a single large screw. Once it is displaced, it can be treated as any olecranon fx is treated (screw +/- tension band, or plate fixation).

The referenced study by Rettig et al is a case series of five pitchers who underwent ORIF with a 7.0mm screw for this pathology. All went onto successful union at a mean of 15.4 weeks with return to throwing at a mean of 29 .4 weeks.

Illustration A depicts a compression screw and tension band construct with healed olecranon stress

 

arthroplasty?

 

 

 

A 40-year-old laborer severe glenohumeral arthritis and irrepairable rotator cuff tear. A 40-year-old with a painful proximal humerus malunion.

 

 

A 75-year-old woman with severe arthritis and active overhead motion.

 

 

 

 

 

 

A 75-year-old man with painful arthritis and a massive irrepairable rotator cuff tear Failed hemiarthroplasty due to significant glenoid wear.

CORRECT ANSWER: 4

The indications for reverse total shoulder arthroplasty includes symptomatic arthritis in an elderly person with irreparable cuff tear with evidence of arthropathy. The patient must have a functioning deltoid. There is concern for glenoid component loosening in younger, more active patients. Drake et al found "in short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA".

Goutallier describes good results for a reverse TSA in patients with a superiorly "migrated humeral head and abnormal cuff function".

 

 

1. The superior glenohumeral ligament is under the greatest stress when the humeral head and arm are in which of the following positions?

    

    

    

   Anteriorly translated with the arm in 90 degrees of abduction and externally rotated Inferiorly translated with the arm in 5 degrees of adduction

    

    

    

    

    

    

   Anteriorly translated with the arm in 90 degrees of abduction and internally rotated Inferiorly translated with the arm in 45 degrees of abduction and internal rotation Inferiorly translated with the arm in 90 degrees of abduction and neutral rotation

   CORRECT ANSWER: 2

   The role of each glenohumeral ligament has been clearly defined by previous cadaveric studies that have sectioned different ligaments during different periods of stress on the glenohumeral joint.

   These studies have demonstrated that the superior glenohumeral ligament provides the most restraint to the shoulder joint when the arm is at zero degrees of abduction or in adduction and pulled inferiorly.

   Warner et al. tested 11 cadavers with varying amounts of abduction and rotation to see what ligaments provided specific, directional stability to the shoulder joint. They found that the anterior and posterior bands of the inferior glenohumeral ligament provided the most restraint when the arm was abducted. In addition, they found the superior glenohumeral ligament provided the most restraint when the arm was at zero degrees of abduction and pulled inferiorly.

   Illustration A shows an anatomic representation of the glenohumeral ligaments. Incorrect answers:

   1: The anterior inferior glenohumeral ligament is stressed when the arm is in this position 3 : An arm positioned as such does not classically stress any of the glenohumeral ligaments

   4 and 5: The arm is more adducted in answer 2

    

    

    

    

2. A 35-year-old non-athlete sustains the injury shown in Figure A. An axillary radiograph is also obtained which is normal. Which of the following outcomes has been shown to be associated with reduction and stabilization?

    

    

    

    

    

    

    

    

    

   Improved patient reported outcomes at 3 months Return to pre-injury sporting activity within 1 year Improved shoulder range of motion (ROM ) Improved strength and endurance

    

    

   Improved cosmesis

   CORRECT ANSWER: 5

   The treatment for type III acromioclavicular (AC) joint injuries in non-athletes remains controversial. Multiple studies have demonstrated that with the exception of improved cosmesis with operative treatment, there is no difference in functional and patient-reported outcomes between nonoperative and operative management.

   Type III AC injuries are those with complete rupture of the AC and coracoclavicular (CC) ligaments. Historically, nonoperative management of this type has yielded good results. It is currently debatable whether anatomical stabilization of AC joint dislocation benefits shoulder function. Stabilization techniques include CC screw fixation, coracoacromial ligament transfer, and myriad methods of CC ligament reconstruction.

   Murray et al. published a prospective, randomized, controlled trial comparing patient outcomes following nonoperative care versus fixation for high-grade AC injuries, including types III and V. They reported that while the mean degree of radiographic displacement was significantly less in patients following fixation, there was increased DASH scores in favor of nonoperative treatment and no difference in the mean Oxford Shoulder Score between the 2 cohorts. They concluded that surgical fixation confers no functional benefit over nonoperative treatment at 1 year following high-grade disruptions of the AC joint.

   Lemos reviewed the evaluation and treatment of the injured AC joint in athletes. He reported that the management of type III AC injuries remains controversial, with many studies demonstrating

   nonoperative treatment as equal, if not superior to operative treatment. He recommended that type III injuries be treated symptomatically and only operated on when nonsurgical treatment fails.

   Figure A depicts a type III AC injury, defined by a torn AC and CC ligaments, with increased CC distance between 25%-100%. Illustration A depicts the Rockwood classification for AC injuries. Incorrect Answers:

   Answer 1: While some studies have definitively demonstrated improved patient-reported outcomes at 3 months with nonoperative management, this has not been the case with operative management. Answer 2: Return to sport at 1 year has not been shown to be significantly different between nonoperative and operative treatment.

   Answers 3 and 4: Improved shoulder ROM, strength, and endurance has not been shown to be superior with operative management.

    

    

    

    

3. Figure A exhibits arthroscopic images during posterior debridement of an overhead athlete. Excessive resection and removing normal olecranon most likely will lead to what pathology when returning to play?

    

    

    

    

    

    

    

   Medial epicondylitis Valgus elbow instability Lateral epicondylitis

    

    

    

    

   Posterolateral rotatory instablity Olecranon stress fracture

   CORRECT ANSWER: 2

   Excessive resection of the posteromedial olecranon can lead to an valgus instability due to iatrogenic medial ulnar collateral ligament laxity due to repetitive stress.

   Valgus extension overload and posteromedial impingement typically develop from the repetitive stress placed on the elbow seen in throwers. This is most commonly associated with medial-sided laxity and results in the formation of posteromedial olecranon osteophytes due to the mechanical abutment of the olecranon against the humerus. When symptomatic, these osteophytes may be treated with either open or arthroscopic excision. However removal of excessive bone may compromise the biomechanical stability of the medial collateral ligament, leading to laxity and pain with valgus stress testing.

   Kamineni et al. performed a biomechanical study and demonstrated a stepwise increase in valgus angulation after resecting the posteromedial olecranon in increments of 3mm (from 0-9 mm). The authors recommend that bone removal from the olecranon should be limited only to osteophytes without the removal of normal bone.

   Ahmad et al. describe the valgus extension overload phenomenon upon return to play, noting that surgical treatment should be limited to the resection of osteophytes only; normal olecranon should not be resected in order to avoid valgus instability.

   Illustration A and B are radiographs showing formation of posteromedial olecranon osteophytes (white arrows).

   Incorrect Answers:

    

    

   Answer 1,3,4 and 5: None of these injury patterns are associated with excessive resection of the posteromedial olecranon and resultant valgus instability.

    

    

    

    

    

4. A 34-year-old competitive weightlifter presents with increasing pain during bench

   pressing. Despite modifications in his workout, he is unable to compete. His physical exam demonstrates weakness in external rotation. Radiographs are unremarkable. His MRI findings are seen in Figure A. Treatment should include which of the following?

    

    

    

    

    

    

    

   Refrain from weightlifting for a minimum of 6 weeks Physical therapy with rotator cuff strengthening Suprascapular cyst decompression

    

    

    

    

   Infraspinatus rotator cuff repair and acromioplasty Spinoglenoid cyst decompression with posterior labral repair

   CORRECT ANSWER: 5

   The clinical and MRI findings in the stem are consistent with a posterior labral tear and associated spinoglenoid cyst. A spinoglenoid cyst could cause nerve compression on the suprascapular nerve before its innervation to the infraspinatus, thus causing weakness in external rotation. In contrast, compression at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles. The suggested treatment in a young and competitive athlete with a spinoglenoid cyst would be spinoglenoid cyst decompression with posterior labral repair.

   Cummins et al studied suprascapular nerve entrapement and concluded that treatment should be directed toward the underlying cause of the nerve injury. Nonoperative management showed a high rate of failure in the treatment of ganglion cysts. Operative decompression of the suprascapular nerve was associated with a high rate of pain relief and functional improvement.

   However, resolution of muscle atrophy was less predictable.

   Martin et al looked at the results of nonoperative treatment for suprascapular neuropathy confirmed by EMG. Their results suggest that in the absence of a well defined lesion producing mechanical compression of the suprascapular nerve, suprascapular neuropathy could be treated nonoperatively.

    

    

5. A patient undergoes an MRI arthrogram for recurrent shoulder instability. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. What is the most likely diagnosis?

    

   Glenolabral articular disruption (GLAD )

    

    

    

    

    

    

    

    

   Humeral avulsion of the glenohumeral ligament (HAGL ) Superior labrum tear from anterior and posterior (SLAP ) Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA ) Partial articular-sided supraspinatus tendon avulsion (PASTA )

   CORRECT ANSWER: 2

   Humeral avulsion of the glenohumeral ligament (HAGL) occurs when the IGHL tears away from its humeral insertion without an associated subscapular tear. The classic teaching is that HAGL lesions requires open repair of the capsule, whereas the other lesions listed are felt to be better addressed with an arthroscopic approach.

   According to the literature review by Stein et al., patients with significant glenoid bone loss, attenuated capsulolabral tissue, engaging Hill-Sachs lesions, and HAGL lesions are contraindicated for arthroscopic repair. They state that while arthroscopy has better cosmesis, decreased perioperative morbidity, decrease loss of external rotation, and is valuable in the confirmation of the

   extent and severity of shoulder instability, for these lesions open techniques are the gold standard. More recent studies support that arthroscopic treatment of HAGL lesions can still be effective in skilled hands.

   The Neviaser article discusses good results for arthroscopic debridement of GLAD lesions for pain relief.

    

    

6. A 23-year-old offensive lineman had an arthroscopic anteroinferior labral repair 1 year ago for shoulder instability. He has continued to have recurrent instability. Below is the preoperative MRI from 1 year ago. What is the most likely cause of the recurrent instability?

    

    

    

   Anteroinferior labral nonunion

    

    

    

    

   Unrecognized humeral avulsion of the glenohumeral ligament (HAGL ) Anteroinferior glenoid bone defect

    

    

    

    

   Engaging Hill Sachs defect Untreated SLAP lesion

   CORRECT ANSWER: 3

   The MRI reveals an anteroinferior glenoid fracture (bony Bankart). This was not addressed at initial surgery as the patient only underwent a soft tissue Bankart repair.

   Burkhart et al performed a combined cadaveric and cohort study of patient's without shoulder instability. They examined the use of the glenoid bare spot as a reference point for determining anterior glenoid bone loss. They concluded that the glenoid bare spot is reliably found at the center of the glenoid.

   Edwards et al performed a Level 4 review of shoulder instability patients. They found that 73% had the presence of a Hill Sachs lesion and 8% had anterior glenoid bone lesions found on radiographs. Lynch et al performed a Level 5 review of shoulder instability in the setting of concomitant osseous defects. Soft tissue procedures have a high failure rate when glenoid bony deficiency >25% exists.

    

    

7. A 24-year-old bodybuilder reports shoulder pain after an injury while bench pressing. Physical exam reveals ecchymosis and swelling in his right upper arm as shown in Figure A. He has weakness in internal rotation but has good strength in external rotation and abduction; his apprehension test is negative. When he puts his hands on his hips, his upper chest is asymmetrical. When is surgery indicated for this injury?

    

    

    

   Surgery is not indicated; conservative management including ice, rest and NSAIDs are recommended

    

    

    

    

    

    

   After a period of immobilization, followed by physical therapy, has failed When the pectoralis major has avulsed from its humeral insertion Asymmetry of the upper chest wall without functional deficits

    

    

   If swelling and ecchymosis are primarily located on the chest wall rather than the upper arm

   CORRECT ANSWER: 3

   The injury described in this question is consistent with is a humeral avulsion of the pectoralis major muscle, which should be treated with primary surgical repair.

   Surgical repair is indicated with complete pecto-humeral tears. Tears are often found on history and examination, however the location of tear often is determined by radiographic adjuncts such as MRI. The standard of practice includes suture anchors or bone tunnels into the pectoralis insertion on the humerus.

   Schepsis et al. looked at a retrospective case series of 17 patients with acute and chronic distal pectoralis major muscle rupture. They showed that outcome measures of strength after surgical repair of acute and chronic tears were not significant. However, patients treated operatively fared significantly better than patients treated non-operatively.

   Pochini et al. looked at a prospective cohort of 60 patients treated conservatively vs operatively for pectoralis major muscle rupture. They found that the non-operatively group had more complications and decrease in strength of 41.7% relative to 4.3% for the surgical group. Figure A shows bruising in the right axilla consistent with physical exam findings of a pectorals major tear. Illustration A shows a T2 weighted MRI with a retracted pectoralis major tendon (straight solid arrow). There is periosteum (curved arrow) pulled off the humeral cortex adjacent to the biceps tendon and hemorrhage within the muscle (open arrow).

   Incorrect Answers:

   Answer A and B: Operative outcomes show significantly better results than non-operative outcomes.

   Answer D: Asymmetry of the chest wall can result from a spectrum of pectorals major tears, including bony tendon avulsions, mid-tendon and musculotendinous tears. Asymmetry of the chest wall alone, does not warrant surgical intervention. Tear location, function and patient factors must also be considered.

   Answer E: Swelling and ecchymosis over the chest wall is likely indicative of a complete or incomplete mid-substance pectoralis major tear. These injuries typically do not benefit from surgery.

    

    

    

    

8. A freshman collegiate swimmer complains of right shoulder pain after increasing his workout duration and intensity. He denies trauma and admits to popping his shoulders in and out voluntarily since the age of 8. Exam reveals bilateral anterior shoulder apprehension and

    

   active compression tests are negative bilaterally. Radiographs are normal and MR arthrogram of his right shoulder is shown in Figures A and B. What is the best initial treatment?

    

    

    

    

    

    

    

    

    

    

    

   Shoulder range of motion program with emphasis on posterior capsular stretching Shoulder arthroscopy with anterior and posterior capsulolabral plication with superior shift Shoulder arthroscopy with thermal capsulorrhaphy and rotator interval closure

    

    

   Shoulder arthroscopy with repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion

    

    

   Rotator cuff and peri-scapular muscular strengthening program

   CORRECT ANSWER: 5

   This patient has multidirectional shoulder instability a(MDI) and the initial treatment strategy is physical therapy to strengthen the rotator cuff and periscapular muscles to actively compress the humeral head into the glenoid cavity and support the shoulder girdle. The MRI demonstrates posterior capsular redundancy and an intact anterior and posterior labrum. Any patient with history and exam findings of MDI should initially undergo physical therapy.

   The reference by Levine et al. reviews the treatment strategy of MDI and discusses the potential need for operative intervention which include open capsular shifts in non-overhead contact athletes or for revision surgery.

   The Robinson et al article reviews posterior instability and the multi-factorial nature and various treatments for this problem.

    

    

    

9. A 51-year-old diabetic female has been treated with nonoperatively for left shoulder stiffness for the last six months. Despite physical therapy and two corticosteroid injections, she has only been able to achieve 15 degrees of external rotation. She elects arthroscopic treatment. Which of the following interventions would best mitigate the chances of her developing the most common complication of surgical treatment? Perioperative prophylactic intravenous antibiotic administration

 

 

Avoidance of inadvertent division of the subscapularis tendon

 

 

 

 

Post-operative oral non-steroidal anti-inflammatory drug (NSAID) usage Immediate range of motion and physical therapy

 

 

Taking care not to divide the inferior capsule further than the thickness of the capsule alone

CORRECT ANSWER: 4

This patient has adhesive capsulitis. The primary treatment is nonoperative with a gentle home stretching program, as this is a self-limited process that can take up to 18 months to resolve. If arthroscopic capsular release is attempted, the most common complication is recurrent stiffness. Infection, instability, impingement syndrome, recurrent stiffness, and axillary nerve injury are all potential complications of arthroscopic capsular release for the treatment of adhesive capsulitis. However, recurrent stiffness is the most common complication and can be mitigated by immediate early motion and physical therapy with no sling usage. Continuous passive motion machines may be considered as an adjunct. Pain control is important, and regional anesthesia techniques can be helpful in the perioperative period.

Pollock et al. treated 30 shoulders with arthroscopic release for resistant adhesive capsulitis and achieved satisfactory results in 25 (83%). Those with diabetes fared more poorly, with satisfactory results in only 64%.

Yoon et al. randomized 66 patients to receive either subacromial injection, intra-articular injection or hydrodilatation (HD) for treatment of adhesive capsulitis. They found that HD patients had less pain and better function at one month and three months but there were no differences among groups at 6 months. They concluded that HD offered more rapid improvement, but that the three injection techniques offered similar benefits at final follow up.

Sun et al. performed a systematic review and meta-analysis of eight randomized, controlled trials of the effects of intra-articular corticosteroid injection for frozen shoulder. Patients who received injection had less pain and more passive external rotation and abduction at all time points studied (up to 26 weeks). They concluded that steroid injection was a safe and effective treatment for frozen shoulder, resulting in pain relief, functional improvement and increased range of motion at

4-6 weeks, 12-16 weeks and 24-26 weeks post-intervention. Incorrect Answers

Answer 1: Routine use of prophylactic antibiosis is recommended but infection is not as common as stiffness.

Answers 2 and 5: Iatrogenic injury to nerve or tendon should be carefully avoided but stiffness is more common.

Answer 3: NSAIDs may be useful for controlling post-operative pain and inflammation and therefore secondarily prevent recurrent stiffness but are less critical than motion and therapy.

 

 

42 ) A 24-year-old minor league baseball pitcher presents with shoulder pain. On exam, his strength is normal. At 90 degrees of abduction, he has a total arc of motion of 150 degrees and a loss of internal rotation of 30 degrees. His scapula hangs lower than on the nonthrowing shoulder. Initial management should consist of

 

 

 

shoulder arthroscopy and SLAP repair shoulder arthroscopy and a capsular release

 

 

intra-articular cortisone injection, rest and a pitching program

 

 

 

 

diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection aggressive physical therapy involving posterior capsular stretching and scapular strengthening

CORRECT ANSWER: 5

Initial management in throwing athletes with shoulder pain includes rest from throwing with rehabilitaion to improve motion and strength, regardless of the pathology. This patient has glenohumeral internal rotation deficit (GIRD) with external rotation gain (ERG), which is often seen in asymptomatic throwers. However, the total arc of motion should equal 180 degrees, according to the total motion concept. Burkhart et al discuss the typical Type II SLAP tear seen in pitchers, indicating that posterior capsule tightness increases the risk of this injury. They advocate stretching the posterior capsule and strengthening the entire kinetic chain, including the scapular stabilizers. Braun et al arrive at similar conclusions, and maintain that injections and surgery should be reserved for patients who fail to respond to rest and rehabilitation, with few exceptions.

 

 

1. Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program?

    

   Functionally limiting pain

    

    

    

    

   Decreased range of motion compared to contralateral shoulder Recurrence of adhesive capsulitis

    

    

    

    

   Need for operative intervention Development of rotator cuff arthropathy

   CORRECT ANSWER: 2

   The most common outcome following non-operative management of adhesive capsulitis with a stretching program is decreased range of motion compared to the contralateral side.

   Adhesive capsulitis is defined as painful loss of motion of a shoulder without an underlying cause. While it is generally believed to be a self-limiting condition, numerous treatment methods have been suggested including benign neglect, steroid injections, physical therapy, manipulation, and arthroscopic or open capsular releases. Intra-articular steroid injections may provide an earlier return of shoulder range of motion, but have not shown a long-term difference. Non-operative management with a stretching program shows high rates of patient satisfaction, but it is commonly associated with decreased range of motion compared to the contralateral extremity. Griggs et al. reviewed 75 patients with phase-2 adhesive capsulitis who were treated nonoperatively with a stretching program. At an average follow-up of 22 months, forward flexion increased by 19 degrees, but still remained 36 degrees less than the unaffected shoulder.

   Shaffer et al. reviewed 62 patients with adhesive capsulitis who were treated non-operatively with a stretching program. At an average follow-up of 7 years, 60 % of patients had decreased range of motion in at least one plane when compared to a control-group of normal shoulders.

   Incorrect Answers:

   Answer 1: While continued pain is a frequent complication, it is usually much improved from the initial onset of the disease and does not affect quality of life.

   Answer 3: Adhesive capsulitis is thought to have a low recurrence rate after it has resolved. Answer 4: Surgical intervention following non-surgical management of adhesive capsulitis is rare since >90% report satisfaction with non-operative treatment.

   Answer 5: The association between rotator cuff arthropathy and adhesive capsulitis has not been studied.

    

    

2. A 25-year-old wrestler, who you have been following for 1 year for persistent shoulder pain, presents to your office. He reports that his shoulder pain has not improved despite a period of rest with directed physical therapy and a cortisone injection. On exam, he has full passive and active range of motion. He is tender over the AC joint and has pain but no weakness with resistance while the arm is adducted and flexed forward. Figure A-C show his recent MRI. What is the next best step in treatment?

    

    

    

    

    

    

    

    

   SLAP repair

    

    

    

    

    

    

   SLAP repair with biceps tenodesis Subpectoral biceps tenodesis Distal clavicle excision

    

    

   Anatomic coracoclavicular ligament reconstruction with distal clavicle excision

   CORRECT ANSWER: 4

   This patient's history and exam findings are classic for distal clavicle osteolysis. Conservative treatment options have been exhausted and he would therefore benefit most from a distal clavicle excision at this time.

   Distal clavicle osteolysis is due to repetitive stress and micro-fractures leading to bone resorption. It is most commonly seen in weightlifters who bench press or from similar activities placing undue traction through the AC joint. A trial of rest, NSAIDs, physical therapy and modified weightlifting technique (avoiding manoeuvres with the elbows posterior to the torso) have shown to be successful in mitigating symptoms. If symptoms persist, open or arthroscopic distal clavicle excision is indicated. The arthroscopic approach has the added benefit of allowing concomitant pathology to be addressed.

   Auge et al. reported on a series of 10 arthroscopic distal clavicle excisions performed on weightlifters with distal clavicle osteolysis. All athletes returned to sport at an average of 3.2 days, returned to weight training at 9.1 days, and had increased strength and work volume. This demonstrates the effectiveness of arthroscopic excision in relieving symptoms in the athlete population.

   Roedl et al. reviewed outcomes of distal clavicle osteolysis at a single institution. The mean age was 15.9 years with most participating in overhead sports and/or weightlifting. They found that 93% of patients responded to conservative treatment and that MRIs performed at follow-up showed an average of 5mm of AC joint widening. Their findings support the theory of overhead and weightbearing activities having an important role in the development of distal clavicle osteolysis.

   Figures A-C are fluid-sensitive MRI images showing edema within the distal clavicle and AC joint. Illustration A and B are pre- and post-operative x-rays of a patient after an arthroscopic distal clavicle excision.

   Incorrect Answers:

   Answers 1 and 3: Though superior labral and biceps pathology is seen in wrestlers, this patient's symptoms and exam are most consistent with distal clavicle osteolysis.

   Answer 2: Some degree of weakness would be expected with a rotator cuff tear. Answer 5: Instability related to AC separation would be the inidication for CC ligament reconstruction, however the history and images are more consistent with distal clavicle osteolysis.

    

    

    

    

    

    

    

3. A 23-year-old wrestler presents to your office after suffering his fourth anterior shoulder dislocation in one year. A radiograph and MRI are obtained and are shown in Figures A and B, revealing a bony avulsion. Under normal circumstances, in what situation is the ligament that attaches to this avulsed bone subjected to the highest stress?

    

    

    

    

    

    

    

   Inferior force in 0 degrees of abduction

    

    

    

    

    

    

   Anterior force in 90 degrees of abduction and external rotation Anterior force in 45 degrees of abduction and external rotation Posterior force in 90 degrees of forward flexion and internal rotation Posterior force in 45 degrees of abduction and external rotation

   CORRECT ANSWER: 2

   The figures show a humeral avulsion of the glenohumeral ligaments (HAGL) lesion. With the shoulder abducted and externally rotated to 90 degrees, the anterior inferior glenohumeral ligament (aIGHL) is fully taut and vulnerable to injury, sometimes leading to an avulsion from the humeral attachment.

   Anterior shoulder instability is a common condition that involves various structures in the shoulder. The anterior band of the inferior glenohumeral ligament is a critical stabilizer with the shoulder in the vulnerable position of 90 degrees of abduction and external rotation. With anterior dislocation or subluxation, a spectrum of injuries to the aIGHL, labrum, bone, and/or cartilage may occur.

   HAGL lesions usually occur during hyper-abduction with external rotation events and are best seen on MRI. Anatomic variations have been described including humeral bony avulsions and ligamentous avulsions ( bony HAGL) with concomitant capsulolabral detachment (floating anterior IGHL).

   Bui-Mansfield et al. reported a case series of HAGL lesions. All cases involved males who had undergone a large traumatic event. They noted that all HAGL lesions were found in conjunction with other pathology both intra-articular ( long head of biceps tear, Bankart lesion, humeral OCD) and extra-articular (RTC tears and clavicle fractures).

   George et al. reviewed the management of HAGL lesion. They reported more severe anterior shoulder pain in cases of HAGL lesions and recommend a high index of suspicion for an unrecognized HAGL lesion in cases of persistent instability. Arthroscopic and open techniques are both described with successful results, however, it may be more challenging arthroscopically as it often requires the use of a 70-degree arthroscope and uncommon accessory portals. Figure A is a radiograph showing a bony HAGL lesion. Figure B is a T2 coronal MR image showing the classic appearance of a HAGL lesion. Illustration A is a radiograph with a more apparent bony HAGL lesion (Bui-Mansfield et al). Illustration B shows an MR image with the curved arrow labeling the J-shaped IGHL and black arrow noting the fluid extravasation (BuiMansfield et al).

   Illustration C depicts the glenohumeral ligaments (George et al) Incorrect Answers:

   Answer 1: The SGHL is taut at 0 degrees of abduction and resists inferiorly directed forces Answers 3 and 5: With the shoulder at 45 degrees of abduction the MGHL is taut and resists both anteriorly and posteriorly directed forces

   Answer 4: The posterior IGHL is taut in 90 degrees of abduction with external rotation and resists posteriorly directed forces

    

    

    

    

    

    

    

    

    

4. A 24-year-old rugby player presents to you for recurrent shoulder injuries. He has tried physical therapy which has not helped and he could not tolerate bracing. Based on his imaging is shown in Figures A-D, you recommend surgery. What procedure(s) is indicated and what additional restrictions would this require post-operatively?

    

    

    

    

    

    

    

    

    

    

    

    

    

   Rotator cuff repair, avoid internal rotation and active abduction Latarjet procedure, avoid external rotation and abduction

    

    

    

    

    

    

   Arthroscopic bankart repair and remplissage, avoid abduction in the scapular plane Arthroscopic bankart repair and remplissage, avoid forward flexion and adduction Latarjet procedure, avoid resisted elbow flexion and supination

   CORRECT ANSWER: 4

   The imaging shows a large anterior labral Bankart lesion and a Hill-Sachs lesion. The most likely procedure needed to be performed in conjunction is a remplissage procedure. This requires avoiding the vulnerable position of adduction and forward flexion (analogous to the Jerk test in the posterior instability setting). Forward flexion and adduction tensions the posterior capsular structures and would jeopardize the repair.

   Anterior shoulder instability is a common occurrence among collision sports, with rugby and American football being the most common. Recurrence rates are indirectly correlated to age, with teenage athletes seeing rates of approximating 90%. In-season bracing is effective in limiting further dislocations until post-season surgery to address the Bankart lesion can be performed.

   Associated lesions seen in anterior instability are Hill-Sachs defects, HAGL lesions, and GLAD lesions. Hill-Sachs are most often treated with remplissage procedure if they are "off-track" and engaging. Remplissage involves placing the infraspinatus tendon and posterior capsule into the defect rendering it extra-articular.

   Zhu et al. reported a series of patients undergoing anterior stabilization with arthroscopic bankart repair and remplissage. Forty-nine patients underwent this procedure with clinically significant increases in Rose, ASES and Constant scores at an average follow-up of 29 months. Decreases in internal rotation were recorded at under 2 degrees, showing this method as a feasible alternative to prior techniques.

   Parnes et al. reported their technique of arthroscopic remplissage. They used a transtendinous suture anchor repair, where limbs from both anchors were tied together and pulled down in a pulley fashion. This can be visualized either intra-articularly or subacromially and has the advantage of placing a broad portion of infraspinatus/capsule into the defect. Post-operative external rotation immobilizer is used briefly to limit internal rotation or forward flexion and protect the posterior capsular repair.

   Figure A is a normal AP radiograph of the right shoulder. Figures B-D are fluid sensitive MR arthrogram images showing a large anterior Bankart lesion without bone loss and a Hill-Sachs lesion. There is no fatty atrophy of the rotator cuff muscles. Illustration A is from Zhu et al. and demonstrates the remplissage procedure. Illustrations B-D are from Parnes et al. showing an arthroscopic remplissage with a pulley method.

   Incorrect Answers:

   Answer 1- Rotator cuff tears may occur after dislocations, but the imaging shows intact rotator cuff tendons and no muscle atrophy.

   Answers 2 and 5- Latarjet is done to augment large anterior bony defects, which this patient does not have. Additionally, elbow flexion and supination should be incorporated in early rehab to avoid elbow stiffness.

   Answer 3- Adduction, not abduction should be avoided in post-op rehab after remplissage.

    

    

    

    

    

    

    

    

    

    

    

    

5. A 58-year-old right-hand-dominant firefighter presents with a chief complaint of chronic right elbow pain. He denies prior trauma. He has previously tried non-steroidal antiinflammatories, physical therapy, and corticosteroid injections without significant relief. On physical exam, he is well-built without gross deformity, his active and passive range of motion is 30-130 (extension-flexion) degrees, pronation is 70 degrees, and supination is 85 degrees. He exhibits crepitus on exam and has some tenderness at end-range of motion. Radiographs are obtained and are presented in Figures A and B. What is the most appropriate treatment option at this time with the most predictable pain relief?

    

    

    

    

    

    

    

    

   Repeat corticosteroid injection and physical therapy Static splinting

    

    

    

    

   Arthroscopic debridement Interposition arthroplasty

    

    

   Open debridement

   CORRECT ANSWER: 3

   In a younger, high-demand patient with moderate elbow osteoarthritis failing non-operative management, the next best treatment of choice would entail arthroscopic debridement. Arthroscopic debridement provides more reliable pain relief than open debridement, which provides more predictable improvements in range of motion. This patient has an acceptable motion arc and his primary complaint is pain.

   Symptomatic primary elbow arthritis is rare and primarily affects middle-aged male laborers. The radiocapitellar joint is primarily affected, and osteophytes, capsular contracture, and loose bodies are the main contributors to pain and functional impairments. Initial treatment is non-operative, with a trial of nonsteroidal anti-inflammatories, resting splints, activity modification, and physical therapy. Operative treatment depends on age, activity demands, degree of arthritis, and specific pathology. Major indications for elbow arthroscopy include irrigation and debridement in the setting of septic arthritis, synovectomy for inflammatory arthritis, debridement and loose body removal for osteoarthritis, contracture release, treatment of osteochondral defects, and lateral epicondyle release in the setting of tennis elbow. With more advanced radiocapitellar arthritis, radial head replacement is a consideration. Total elbow arthroplasty is not advised in younger, high-demand patients, as there is a lifetime 5-10 pound lifting restriction following this procedure. Pitta et al. provide a review article on the arthroscopic management of osteoarthritis in general. They comment on the controversial role of arthroscopy in the setting of osteoarthritis and conclude that arthroscopy may still serve as an effective and less-invasive option in certain clinical situations.

   Elbow arthroscopy for osteoarthritis often involves the removal of loose bodies, osteophyte resection, and capsular release. Arthroscopy appears to more reliably relieve pain than improve motion.

   Sears et al. discuss the evaluation and management of post-traumatic elbow arthritis in a younger demographic. They note that, due to high functional demands, total elbow arthroplasty is a salvage procedure in this cohort; advanced cases of elbow osteoarthritis are often better addressed with resurfacing procedures or interposition arthroplasty. They conclude that the goal of surgery in this group is to improve pain and functional motion in a conservative manner as to not exclude surgical options down the road.

   Figures A and B are anteroposterior and lateral radiographs of a right elbow, respectively, demonstrating moderate osteoarthritis. The joint spaces are relatively well preserved in the anteroposterior view. Osteophytes are identified at the anterior humerus, coronoid tip, and olecranon. Illustrations A and B are axial and sagittal computed tomographic scans of the elbow demonstrating osteophyte formation in the olecranon and coronoid fossae, as well as osteophytes at the coronoid and olecranon tips.

   Incorrect Answers:

   Answer 1: Repeating corticosteroid injections and physical therapy are unlikely to benefit this patient, as he has failed these non-operative modalities previously.

   Answer 2: Static splinting is a treatment option for contractures about the elbow, however, this patient has a functional arc of motion and his chief complaint is pain.

   Answer 4: Interposition arthroplasty may be a treatment option in a younger, high-demand patient who would otherwise be a candidate for a total elbow arthroplasty.

   Answer 5: Open debridement is more reliable at improving range of motion, whereas arthroscopic debridement is more reliable at relieving pain. This patient has adequate motion and his chief complaint is pain.

    

    

    

    

    

    

    

6. A 67-year-old male presents with left shoulder pain. He underwent surgery on his left shoulder 10 years prior. Initially, he was pain-free following surgery, however, his pain has returned and has been increasing in intensity. On physical examination, his incision is healed with no erythema. He actively exhibits 120° of forward flexion, 25 ° of external rotation, and internal rotation to L3. He exhibits 5/ 5 strength with forward flexion, internal rotation, and external rotation. He has a negative belly-press test, negative hornblower's sign, and a negative Spurling's test. Distally, he is neurovascularly intact. Joint aspiration is performed in the office and reveals a white blood cell count (WBC) of 1900 x10^9/L, with 20% polymorphonuclear leukocytes (PMNs). Cultures were held for 3 weeks and exhibited no

   growth to date. Radiographs are obtained and shown in Figures A & B. Which of the following is the next best step in the treatment of this patient?

    

    

    

    

    

    

    

    

   Magnetic resonance imaging (MRI) of the shoulder to evaluate the rotator cuff Humeral head revision and placement of prosthetic glenoid component

    

    

   Two-stage revision with placement of an antibiotic spacer

    

    

   Revision total shoulder arthroplasty with a cemented humeral stem 5. Revision to an implant with a center of rotation that is moved inferomedially

   CORRECT ANSWER: 2

   Figures A and B demonstrate a left shoulder hemiarthroplasty with associated glenoid erosion. The next best step in this patients treatment is a revision of the humeral head and placement of a prosthetic glenoid component.

   Shoulder hemiarthroplasty (HA) is currently used to treat glenohumeral arthritis and treatment for proximal humerus fractures. It has been increasingly utilized in younger active patients with glenohumeral arthritis due to the risk of glenoid loosening. Some patients treated with HA will

   continue to complain of pain which may be associated with glenoid arthritis and wear. For patients who experience this, a revision to total shoulder arthroplasty (TSA) is the treatment of choice. With the advent of modular systems, the humeral stem may be retained with the placement of a prosthetic glenoid component.

   Groh et al. performed a study to determine the difficulty and results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular systems. 15 patients who underwent revision from hemiarthroplasty to total shoulder arthroplasty were reviewed. They found that revision of HA to TSA was associated with pain relief as well as improvement in forward elevation. They conclude that the revision of painful HA for glenoid arthrosis to TSA is a reliable procedure.

   Carroll et al. evaluated the outcomes of patients after conversion of painful HA to TSA. They found 3 excellent results, 5 satisfactory results, and unsatisfactory results in 7. 7/11 patients had posterior glenoid erosion. They conclude that revision of a failed HA to a TSA is a salvage procedure whose results are inferior to those of primary TSA.

   Figure A is an AP radiograph of the shoulder demonstrating a well-fixed hemiarthroplasty with glenoid erosion. Figure B is an axillary radiograph demonstrating the same.

   Illustrations A & B are AP and axillary radiographs, respectively, demonstrating conversion of the hemiarthroplasty to a total shoulder arthroplasty.

   Incorrect Answers:

   Answer 1: MRI is not indicated to evaluate the rotator cuff as the patient's rotator cuff appears to be intact from the physical examination. Visualization of the rotator cuff would also be difficult given the presence of a hemiarthroplasty.

   Answer 3: Two-stage revision with an antibiotic spacer is unnecessary as this patient does not exhibit signs of infection, and cultures were negative at 3 weeks.

   Answer 4: Explantation and revision to a total shoulder arthroplasty would not be appropriate, as removal of the current, well-fixed humeral stem would add significant morbidity to the procedure. Answer 5: Revision to a reverse total shoulder arthroplasty at this time would not be appropriate, as the patient has a functioning rotator cuff and there is no proximal migration of the stem.

    

    

    

    

    

    

    

7. A 20-year-old male right hand dominant college baseball pitcher presents with 6 months of vague right shoulder pain. He reports decreased performance and pitch velocity as a result of this ongoing problem. On physical exam, he demonstrates the findings shown in Figure A. Which of the following is the most appropriate initial treatment strategy for this patient?

    

    

    

    

    

    

    

   Arthroscopic posteroinferior capsule release Arthroscopic anteriorinferior capsule release Posterior labral repair with capsulorrhaphy

    

    

    

    

   Physical therapy directed at anteriorinferior capsule stretching Physical therapy directed at posteroinferior capsule stretching

   CORRECT ANSWER: 5

   This patient has a finding of glenohumeral internal rotation deficit (GIRD), which can cause shoulder and elbow problems. Internal impingement of the shoulder is one of the most commonly associated syndromes, which is best treated with a course of physical therapy directed at posteroinferior capsule stretching.

   Glenohumeral internal rotation deficit (GIRD) occurs most commonly in overhead throwing athletes and characteristically demonstrates a posterior shift in the glenohumeral range of motion (increased external rotation and decreased internal rotation). Loss of internal rotation of >25 degrees is felt to be clinically relevant GIRD. The first line of treatment consists of rest from throwing and therapy to address rotation deficits. One of the most common stretches is the sleeper stretch, where the patient provides internal rotation to the shoulder with the arm in 90 degrees of abduction. Rarely, patients who fail physical therapy and stretching may be indicated for arthroscopic posterior capsule release.

   Braun et al. reviewed shoulder injuries in throwing athletes. They discuss treatment for GIRD, stating the majority of patients respond to physical therapy. Those few who fail physical therapy are often older, elite athletes and can be treated with arthroscopic posteroinferior capsulotomy in the posterior band of the inferior glenohumeral ligament.

   Crockett et al. looked at 25 professional throwing athletes and 25 nonthrowing patients for range of motion as well as humeral head and glenoid retroversion. They found the dominant shoulder of throwing athletes had significantly greater humeral head and glenoid retroversion as well as external rotation when compared to the non-dominant shoulder. They found no difference in range or motion or retroversion in the dominant versus nondominant shoulders of non-throwing patients. They concluded that the dominant shoulders of throwing athletes have greater retroversion and internal rotation.

   Figure A shows a patient with loss of internal rotation on the right side. Illustration A shows a patient performing a "sleeper stretch", which stretches the posterior capsule in GIRD. Incorrect Answers:

   Answer 1: Arthroscopic posteriorinferior capsule release would only be indicated in rare cases when physical therapy fails to improve the patient's symptoms and range of motion.

   Answer 2: Arthroscopic anterior inferior capsule release is not indicated in cases of GIRD Answer 3: Posterior labral repair with capsulorrhaphy would be indicated in cases of posterior instability more often seen in lineman or weightlifters. Answer 4: The anterior inferior capsule has increased length in GIRD and would not require additional stretching.

    

    

    

    

8. A 52-year-old female with adhesive capsulitis undergoes an arthroscopic release after failure of nonoperative management. Releasing which of the following labeled structures should result in improved cross-body adduction?

    

    

    

    

    

    

    

   A C H

    

    

    

    

   E & C B & D

   CORRECT ANSWER: 3

   Release of the posterior capsule (label H) would result in improved cross-body adduction (adduction of the forward-flexed shoulder) intra-operatively.

   Adhesive capsulitis (frozen shoulder) is a fibroblastic proliferation of capsular tissue of unknown etiology resulting in pain and loss of both passive and active shoulder range of motion. While nonoperative management is successful in the majority of patients, surgery may be considered in recalcitrant cases. Classically, the rotator interval is released to improve external rotation, while the posterior capsule is released to improve internal rotation and cross-body adduction.

   Kim et al. performed a randomized controlled trial of 75 patients with shoulder stiffness to compare outcomes in patients with and without posterior extended capsular release. Despite intra-operative improvements, at final follow-up, the authors found no difference in forward flexion, external rotation, and internal rotation between the groups. They concluded that posterior extended capsular release may not be necessary in the arthroscopic management of shoulder stiffness.

   Snow et al. evaluated the efficacy of posterior arthroscopic release in 48 patients with frozen shoulder. The authors found that, compared to the group that underwent only an anterior and inferior release, patients who also had a posterior release had no difference in Constant Scores and range of motion, particularly internal rotation. They concluded there was no significant difference in outcome with the addition of a posterior release in patients with a frozen shoulder.

   Illustration A shows the capsular and ligamentous structures important for glenohumeral stability.

   Incorrect Answers:

   Answer 1: A shows the long head of the biceps. While its role as a pain generator in various shoulder pathologies has been debated, release of the long head of the biceps would not increase cross-body adduction. Answer 2: C shows the middle glenohumeral ligament (MGHL). The MGHL resists anterior and posterior translation in ~45 degrees of abduction. Answer 4: E shows the anterior band of the inferior glenohumeral ligament ( AB-IGHL), while C shows the MGHL. The AB-IGHL is the primary restraint to anterior and inferior translation with the arm at 90 degrees abduction and maximum external rotation.

    

    

   Answer 5: B shows the superior glenohumeral ligament (SGHL), while D shows the anterior capsule. The SGHL is a restraint to inferior translation at 0 degrees of abduction.

    

    

9. An active 61-year-old male sustains the injury seen in Figure A. After undergoing treatment for this acute condition he continues to have pain and weakness in his shoulder for 6 weeks. Which of the following is the next best step?

    

    

    

    

    

    

    

    

    

    

   Magnetic resonance imaging (MRI) of the shoulder to evaluate the rotator cuff Magnetic resonance imaging (MRI) of the shoulder to evaluate the labrum Electromyography to evaluate for Axillary Nerve Palsy

    

    

    

    

   Computed tomography (CT) of the the shoulder to evaluate the glenoid Computed tomography (CT) of the shoulder to assess for an occult fracture

   CORRECT ANSWER: 1

   This patient sustained an anterior shoulder dislocation. Following shoulder dislocations, elderly patients should be evaluated for rotator cuff tears with MRI.

   Rotator cuff tears following shoulder dislocations have been found to occur in up to 80% of patients over the age of 60. Persistent pain and dysfunction after a shoulder dislocation are signs that a rotator cuff tear may be present and an MRI should be obtained. After a trial of physical therapy, untreated tears may cause persistent pain, dysfunction, instability, and degenerative changes. Surgical treatment of these injuries usually leads to pain relief and restoration of function.

   Gombera et al. performed a systematic review to determine when a rotator cuff tear should be suspected after a dislocation, whether surgical or nonsurgical approaches result in better scores for pain and satisfaction in patients with rotator cuff tears resulting from shoulder dislocations, and whether intraarticular lesions, rotator cuff tears, or both should be addressed when surgery is performed. They found that patients with persistent pain or dysfunction often had a concomitant

   rotator cuff tear and that surgical repair resulted in improved pain relief and higher patient satisfaction compared to non-operative management.

   Wolf et al. performed a review on the indications for repair of full-thickness rotator cuff tears. They report that acute tears are reported to make up 8% of all rotator cuff tears and are usually associated with a traumatic event such as a fall or shoulder dislocation. They report MRI is useful in these situations to evaluate for fatty degeneration, atrophy, and retraction.

   Figure A is an AP radiograph of the shoulder demonstrating medial displacement of the humeral head relative to the glenoid fossa. Figure B is an axillary radiograph of the shoulder that shows the humeral head dislocated anteriorly and impacted on the anterior aspect of the glenoid. Illustration A is a T2-weighted coronal MRI slice demonstrating a full-thickness rotator cuff tear indicated by an arrow. The asterisk delineates distention of the AC joint capsule. Illustration B is a photograph demonstrating a full-thickness rotator cuff tear.

   Incorrect Answers:

   Answer 2: MRI of the shoulder should be obtained to evaluate the rotator cuff, not the labrum. Answer 3: Electromyography would not be the next best test to obtain at this time. Rotator cuff tear is more likely than axillary nerve injury in a patient over 40.

   Answer 4: A CT to evaluate the glenoid is not initially indicated in an elderly patient following a shoulder dislocation. This may be obtained at a later time if arthroplasty is being planned to assess version of the glenoid.

   Answer 5: A CT to evaluate for an occult fracture is not indicated in this scenario.

    

    

    

    

    

    

    

10. A 55-year-old right-handed female presents with left shoulder pain and stiffness. She denies any medical problems. On physical examination, her range of motion is notable for passive and active forward flexion to 100°, abduction to 40°, external rotation to 5° and internal rotation to L5. Imaging of the left shoulder is shown in Figures A and B. Which of the following is most likely to be present in this patient?

     

     

     

     

     

     

     

     

     

    Elevated thyroid stimulating hormone (TSH ) Increased serum uric acid

     

     

     

     

     

     

    Elevated erythrocyte sedimentation rate (ESR ) Positive anti-cyclic citrullinated peptide (anti-CCP ) A history of multiple shoulder dislocations

    CORRECT ANSWER: 1

    This patient has adhesive capsulitis, which has been associated with hypothyroidism, which would show elevated thyroid stimulating hormone ( TSH ).

    Adhesive capsulitis (AC), or frozen shoulder, is a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. It is most commonly seen in women 40-60 years of age.

    Endocrine, immunological, and inflammatory etiologies have been proposed. Thyroid dysfunction, diabetes mellitus, Dupuytren contractures, breast cancer treatment, and autoimmune diseases have been historically associated with AC. A complete workup in patients with newly diagnosed AC should be performed prior to selecting a treatment option.

    Schiefer et al. performed a case-control study to compare patients with AC to controls. A specific questionnaire was applied, and measurements of serum thyroid-stimulating hormone (TSH) and free tetraiodothyronine were performed in all subjects. They found that hypothyroidism was significantly higher in patients with AC. Also, patients with elevated TSH levels had a higher prevalence of bilateral AC. They conclude that hypothyroidism was significantly higher in AC patients than in controls.

    Huang et al. performed a study to determine the prevalence and adjusted hazard ratio (HR) of AC among patients who have hyperthyroidism. They obtained data from a database in Taiwan and records were reviewed. Of 4472 patients with hyperthyroidism, 162 experienced AC (incidence 3.6%). They found the adjusted HR of developing AC was 1.22 which was statistically significant. They conclude that hyperthyroidism is an independent risk factor of developing adhesive capsulitis. Figure A is a normal AP radiograph of the shoulder. Figure B is a T2 weighted MRI demonstrating increased signal of the joint capsule in the axillary recess.

    Incorrect Answers:

    Answer 2: An increased serum uric acid would be consistent with gout. Answer 3: An elevated ESR would be consistent with infection.

    Answer 4: A positive anti-CCP would be consistent with rheumatoid arthritis. Answer 5: A history of previous shoulder dislocation is not associated with AC.

     

     

11. An 18-year-old male presents to the emergency department with left shoulder pain following a seizure earlier in the day. He reports a history of epilepsy and that he has dislocated his left shoulder over ten times. He is inconsistent with taking his seizure medications. A radiograph of his shoulder is shown in Figure A. Upon reviewing his electronic medical record a CT scan of his left shoulder from one month ago is found as demonstrated in Figure B. Which of the following treatment options is the most appropriate at this time?

     

     

     

     

     

     

    Do not attempt closed reduction and admit for closed versus open reduction in the operating room

     

     

    Closed reduction alone

     

     

    Closed reduction and referral to neurology

     

     

     

     

    Closed reduction and outpatient referral for shoulder stabilization procedure Closed reduction and outpatient referral for shoulder fusion

    CORRECT ANSWER: 3

    In patients with epilepsy and shoulder instability, surgery should not be performed until medical management is exhausted. This patient should be closed reduced, referred to neurology, and, once his seizures are under control, considered for shoulder stabilization surgery; bone grafting for his glenoid deficit (>20-25%) would be indicated.

    Large bony defects and degenerative changes are the characteristic findings in epileptic patients with recurrent shoulder dislocations. Muscle contractions and trauma are the main causes of shoulder dislocation during seizure activity. Soft tissue stabilization procedures alone are often unsuccessful, as it is imperative to address the bone loss contributing to recurrent instability in this population. Coracoid transfer (Laterjet) and bone grafting can be successful in these patients when seizures are adequately controlled and patient compliance is optimal.

    Raiss et al. reported on the results of the Laterjet procedure for epileptic patients in the setting of recurrent anterior shoulder dislocations. In their cohort of 12 patients, they reported an unacceptably high failure rate. They concluded that the Laterjet procedure is contraindicated in patients with uncontrolled seizure activity.

    Buhler et al. looked at 34 shoulders in 26 epileptic patients over a 10 year period to examine their pattern of instability and structural lesions. They found an equal rate of anterior and posterior dislocations, characteristically associated with large bony lesions (Hill-Sachs and bony Bankart). They concluded that anterior dislocations are more difficult to treat than posterior dislocations in this group and that skeletal reconstruction is necessary to obtain clinical stability.

    Figure A is a left shoulder radiograph demonstrating an anterior dislocation. Figure B is a left shoulder CT demonstrating significant anterior glenoid bone loss.

    Incorrect Answers:

    Answer 1: There is no reason why a closed reduction attempt should not be attempted in the emergency department.

    Answer 2: A closed reduction alone will not prevent this adolescent from dislocating in the future and does not address his seizures.

    Answer 4: Shoulder stabilization surgery should not be performed until medical management of his seizures is exhausted, as this is associated with a high failure rate. Answer 5: Shoulder fusion is not appropriate at this time.

     

     

12. A 25-year-old male baseball player presents 3 months postoperatively after undergoing repair of the condition shown in Figure A. He is complaining of shoulder pain and weakness. As the operative surgeon, you recall errantly passing instrumentation medial to the glenoid. From which portion of the brachial plexus does the injured nerve arise?

     

     

     

     

     

     

     

     

     

     

     

    Superior trunk Middle trunk Roots of C 5-7 Posterior Cord Medial Cord

    CORRECT ANSWER: 1

    The suprascapular nerve (SSN) arises from the superior trunk of the brachial plexus and may be injured during superior labrum anterior-to-posteror (SLAP) tear repair if instrumentation is passed medial to the glenoid.

    Neuropathy of the SSN is frequently caused by space-occupying lesions. The nerve may also be injured by plating of the glenoid or muscle mobilization during cuff repair. Injuries have also been

    reported with SLAP repairs, especially if anchors or instrumentation are passed medial to the glenoid.

    Cummins et al. performed an anatomic study on the spinoglenoid ligament. They dissected 112 shoulders and found no distinct ligament structure in 20% of shoulders. Overall, 80% of shoulders had a fibrous band of tissue that, together with the spine of the scapula, formed a narrow fibroosseous tunnel through which the suprascapular nerve traveled. They found the ligaments to be composed of collagen on histologic analysis. They conclude that the ligament may limit mobilization and advancement of the infraspinatus tendon during repair of a massive cuff tear and the spinoglenoid ligament represents a potential site for nerve entrapment.

    Kim et al. present a case of a 41-year-old woman who underwent arthroscopic repair of a SLAP lesion with suture anchors. The patient continued to have pain post-operative and MRI revealed that the suture anchor was beyond the cortical bone of the glenoid rim and abutted the SSN. Direct compression of the nerve was visualized with repeat arthroscopy and the suture anchor was removed. The patient became asymptomatic 3 months later. The authors recommend careful placement of suture anchors during repair of SLAP lesions to avoid iatrogenic injury to the SSN. Scully et al. perform a review on iatrogenic nerve injuries in shoulder surgery. They report that due to the intimate relationship of the SSN to the glenoid rim as it traverses the body of the scapula, the nerve is at risk during procedures that involve drilling and passing sutures and/or placing screws around the glenoid face and rim. They report that repair of SLAP tears can result in injury as a result of "drill out," in which the drill perforates the medial glenoid and improper anchor placement. Figure A is T2-weighted MRI slice demonstrating a SLAP tear. Illustration A is a

    T-1-weighted MRI slice demonstrating suture anchors medial to the glenoid ( Kim et al.). Illustration B demonstrates the course of the suprascapular nerve on the posterior scapula with the safe zone depicted with grey shading (Scully et al.) Illustration C demonstrates the safe zones of the glenoid in the transverse plane while Illustration D demonstrates the safe zone in the sagittal plane (Scully et al.).

    Incorrect Answers:

    Answer 2: There are no branches arising from the medial trunk.

    Answer 3: The long thoracic nerve arises from the nerve roots of C5-7. Answers 4 & 5: Many nerves arise from the posterior and medial cords of the brachial plexus, and none of them would be injured by passing instrumentation medial to the glenoid.

     

     

     

     

     

     

     

13. Untreated progression of the condition shown in Figure A may lead to which of the following radiographic appearances shown in Figures B-F?

     

     

     

     

     

     

     

     

     

     

     

     

     

    Figure B Figure C Figure D Figure E Figure F

    CORRECT ANSWER: 4

    A rotator cuff tear can lead to rotator cuff tear arthropathy, characterized radiographically by degenerative changes of the glenohumeral joint and superior migration of the humeral head. Rotator cuff tear arthropathy is a term first used by Charles Neer in 1983. While it is a broad term, all patients with cuff tear arthropathy have at least 3 features in common: a non-functioning rotator cuff, degenerative changes of the glenohumeral joint, and superior migration of the humeral head.

    The accurate diagnosis of rotator cuff tear arthropathy is important, because definitive treatment changes according to whether a patient has a functioning rotator cuff.

    Nam et al. reviewed rotator cuff tear arthropathy. They noted that cuff tear arthropathy always involves the three features of rotator cuff insufficiency, degenerative changes in the glenohumeral joint, and superior humeral head migration. They also pointed out that while there are many patients with rotator cuff pathology, not all develop rotator cuff arthropathy.

    Feeley et al. also reviewed cuff tear arthropathy. The authors stated that, while cuff tear arthropathy has been recognized for decades, a treatment strategy with uniformly satisfactory outcomes remains elusive. They noted that the use of reverse total shoulder arthroplasty to treat this condition showed good results, and is now the standard.

    Figure A shows a complete rotator cuff tear of the supraspinatus and infraspinatus. Figure B shows a chondrosarcoma of the proximal humerus. Figure C shows glenohumeral arthritis without rotator cuff arthropathy. Figure D shows a shoulder dislocation. Figure E shows rotator cuff arthropathy of the glenohumeral joint with superior migration of the humeral head and acetabularization of the acromion. Figure F shows a proximal humerus fracture.

    Incorrect Answers:

    Answers 1 (chondrosarcoma), 2 (glenohumeral osteoarthritis), 3 (dislocation), and 5 (fracture) all show conditions that do not result from the untreated progression of rotator cuff pathology.

     

     

14. A 76-year-old female presents with right shoulder pain and inability to actively forward flex her shoulder past 45 degrees. She has had shoulder pain for years but has had no surgical interventions and comes to discuss shoulder replacement. She has a history of hypertension, diabetes, and is a current smoker. Radiographs are shown in Figures A and B. Which of the

    following should be performed next in preparation for shoulder arthroplasty?

     

     

     

     

     

     

     

     

     

    Smoking cessation program A trial of physical therapy Prescribe tramadol

     

     

     

     

    Lab tests (CBC, ESR, CRP ) Referal to a rheumatologist

    CORRECT ANSWER: 1

    A smoking cessation program should be instituted as smoking has been suggested as a contraindication to reverse and total shoulder arthroplasty ( RSA,TSA ).

    RSA and TSA have been associated with complications including infections, loosening, and fractures. Patient-specific factors that have been demonstrated to increase these complications include a younger age, higher body mass index, rheumatoid arthritis, and diabetes. Specifically, smoking has been found to contribute to higher infection rates and increased risks of fracture and loosening. Smokers who are planning to undergo elective, primary shoulder arthroplasty should be enrolled in smoking cessation programs to decrease their risks for developing a complication. Hatta et al. performed a retrospective study to examine the effect of smoking on the incidence of complications after TSA and RSA. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures, and loosening after surgery. There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Current and former smokers also had significantly higher risks of periprosthetic infections when compared to nonsmokers (hazard ratio of 7.27 and 4.56, respectively). They conclude that smoking is a significant risk factor for complications after TSA and RSA.

    Cheung et al. performed a review of complications in RSA. They report that infection is a relatively common complication in RSA with an incidence of 110 %. They note that patients who present with rheumatoid arthritis are at increased risk of infection. They conclude that regardless of etiology, management of infection is similar to that following other total joint arthroplasty procedures.

    Figure A is an AP radiograph of the shoulder demonstrating proximal humeral migration and cufftear arthropathy. Figure B is a scapular Y view of the shoulder demonstrating the same. Incorrect Answers:

    Answer 2: A trial of physical therapy is not likely to benefit this patient as she has advanced cuff tear arthropathy and pseudoparalysis.

    Answer 3: Tramadol is recommended as first-line treatment of osteoarthritis of the knee.

    Answer 4: CBC, ESR, and CRP should be ordered if one is considering the diagnosis of infection. The likelihood of infection in this scenario is low. Answer 5: Referral to a rheumatologist should be performed if there is clinical suspicion for an unknown diagnosis of rheumatoid arthritis. In this case, the imaging findings are diagnostic and a smoking cessation program should be instituted prior to arthroplasty.

     

     

15. A 21-year old minor league pitcher returns to your office with persistent posteromedial pain in his throwing elbow that worsens after ball release and follow-through. His exam shows full range of motion and some tenderness to palpation over the olecranon. No crepitus is felt medially, and there is no reproduction of the pain while bending the elbow to 90 degrees and pulling the thumb laterally. The rest of the exam is otherwise unremarkable.

    Radiographs are shown in Figures A-B. What is the most likely diagnosis and next best step in treatment?

     

     

     

     

     

     

     

    Ulnar nerve subluxation, extension splinting

     

     

     

     

    Valgus extension overload, physical therapy incorporating flexor-pronator strengthening Medial ulnar collateral ligament injury, ligament reconstruction using palmaris longus autograft Posterolateral rotatory instability, LUCL reconstruction using palmaris longus autograft

     

     

    Medial ulnar collateral ligament injury, PRP injection and physical therapy incorporating flexorpronator strengthening

    CORRECT ANSWER: 2

    Posteromedial elbow pain worse on ball release/deceleration and tenderness over the posteromedial olecranon is classic for valgus extension overload. The best step in treatment is a period of rest and physical therapy focused on strengthening.

    Valgus extension overload is a common condition seen in high-level throwers due to repetitive extension loading of the ulnohumeral joint during the deceleration phase of throwing, resulting in

    high stress at the posteromedial olecranon. Laxity of the medial elbow for any reason will result in a compensatory increase of stress in this area and may result in osteophytes or loose bodies formation. Initial treatment involves a short period of rest from throwing with strengthening exercises of the shoulder, forearm and kinetic chain. If these fail, intra-articular steroid injections are sometimes performed yet there is a paucity of data to support this. When non-operative treatment fails, arthroscopic debridement of the osteophyte and/or cartilage delamination with removal of any loose bodies can be performed with generally excellent results so long as overresection is avoided.

    Dugas reviewed diagnosis and treatment options of this valgus extension overload. Meticulous exam should be performed to differentiate valgus extension overload from medial UCL injuries, ulnar nerve subluxation, ulnar neuritis, and olecranon stress fractures. Oblique radiographs may show osteophyte formation or loose bodies but often symptoms will precede radiographic findings and history and exam should guide diagnosis. Therapy should focus on strengthening the flexorpronator mass given its contribution to dynamic elbow valgus stability, as well as the shoulder and core muscles.

    Ahmad and Conway reviewed management of valgus extension overload. Olecranon pathology can range from osteophyte and exostosis formation to posteromedial tip stress fractures. If nonsurgical means fail, excision of only the osteophyte is indicated, and caution over-resection as iatrogenic medial instability is a common need for second surgery.

    Figures A and B are normal PA and lateral radiographs, as is not uncommon in valgus extension overload.

    Illustrations A and B by Dugas, are oblique and lateral radiographs showing typical osteophyte formation at the posteromedial olecranon.

    Incorrect Answers:

    Answer 1: Ulnar nerve subluxation is palpable during elbow flexion, and sometimes leads to neuritis-type symptoms radiating down towards the hand. Answers 3 and 5: Medial ulnar collateral injuries are common among highlevel throwers, and often produce medial pain during the acceleration phase of throwing. Valgus stress testing at 20-30 degrees of flexion and the milking maneuver will also reproduce pain or instability.

    Answer 4: PLRI is usually due to a traumatic elbow dislocation or iatrogenic injury from a lateral epicondylitis debridement. Lateral pain is common and the chair rise and pivot shift tests will confirm this diagnosis.

     

     

     

     

     

     

     

16. A 50-year-old male laborer has persistent pain in the right elbow and has been having difficulty with some activities of daily living over the last year. He has not seen any progress after 3 months of using the extension splint from his ulnar nerve transposition 10 years ago. He currently denies numbness or tingling in the 4th and 5th digits and has a negative Tinels at the elbow. His elbow range of motion is 45110 ° of flexion/extension and 130° of total pronosupination. Which of these factors is a relative contraindication to arthroscopic release?

     

     

     

    Age over 40 years Male gender

     

     

     

     

    Osteophyte formation in ulnohumeral joint Prior ulnar nerve transposition

     

     

    Heavy labor occupation

    CORRECT ANSWER: 4

    This patient has developed an elbow contracture in the setting of a previous ulnar nerve transposition. Given the variable location of the ulnar nerve, arthroscopy should be avoided and an open release should be performed.

    Elbow contractures may arise from various different insults, from superficial dermal burns to recurrent hemarthroses. Once the functional range of motion needed for most ADLs is lost (100° total arc or from 30-130°), a supervised physical therapy program with or without dynamic splinting is warranted. After these options have been exhausted, surgical release can be considered. An arthroscopic release has several advantages; however, in the setting of a previous elbow surgery (ulnar nerve transposition), this entails a much higher risk of injury and is a relative contraindication. Other contraindications to arthroscopic release are heterotopic ossification, obesity, severe loss of pronosupination, and muscular contractures as seen in cerebral palsy. Keener and Galatz reviewed treatment options for the contracted elbow. Though technically challenging, many elbow contractures are amenable to arthroscopic release. The biggest contraindication to arthroscopic release is a previous ulnar nerve transposition, as portal placement has a much higher risk of iatrogenic nerve injury.

    Tucker et. al discuss the management of elbow contractures arthroscopically. They prefer to resect the entire anterior capsule until the brachialis muscle is seen and always stay posterior to this structure. They also describe making a fenestration between the coronoid and olecranon fossas in order to allow fluid extravasation while working in the posterior compartment.

    Illustration A from Tucker et. al demonstrates anterior joint capsule resection with the brachialis muscle well-visualized. On the right, the brachialis has been retracted anteriorly to protect the neurovascular structures.

    Incorrect Answers:

    Answers 1 and 2: Age and gender are not contraindications to arthroscopic release.

    Answer 3: Arthritis carries a more unpredictable outcome after release but is not a contraindication. Answer 5: Occupation may be a factor in treatment decision-making, but is not a contraindication to arthroscopic release.

     

     

     

     

17. A 55-year-old patient presents with right shoulder pain and weakness after a posterior shoulder dislocation that has not improved with physical therapy. Physical examination reveals pseudoparalysis with pain limiting the range of motion and strength testing. Figure A is the current MRI of the right shoulder. Which structure is most likely injured?

     

     

     

     

     

    Anterior inferior glenohumeral ligament Coracohumeral ligament

     

     

     

     

     

     

    Superior labrum Infraspinatus tendon Posterior labrum

    CORRECT ANSWER: 2

    The MRI demonstrates the subluxation of the biceps tendon, which is associated with the disruption of the coracohumeral ligament (CHL).

    Subluxation of the biceps tendon results from disruption of the bicipital sling, which is formed by the subscapularis, anterior fibers of the supraspinatus, CHL and superior glenohumeral ligament. Patients typically present clinically with anterior shoulder pain and associated clicking during abduction and external rotation. Positive belly press and push-off testing may also be present in the setting of associated subscapularis tears. Treatment initially involves physical therapy and antiinflammatory medications, but refractory cases are treated with arthroscopic or open biceps tenodesis as well as subscapularis repair if a concomitant tear is present.

    Shi et al. performed a prospective study to assess the predictive value of biceps tendon subluxation found on preoperative MRI to the presence of a fullthickness subscapularis tear. The authors reported that of the 26 patients with biceps tendon subluxation preoperatively 9 were confirmed to have a fullthickness subscapularis tear during arthroscopy. The reported sensitivity and specificity of this finding were 82% and 80%, respectively, and a negative and positive predictive value of 97% and 35%, respectively. The authors concluded that the negative predictive value of the absence of biceps tendon subluxation was the most useful.

    Koh et al. performed a retrospective study of patients undergoing arthroscopic and evaluated the angle between the long head of the biceps and the glenoid in patients with and without biceps tendon subluxation. They reported that there was an 87-degree angle in patients with a tendon subluxation and 90degree angle in patients without subluxation, which was statistically significant (p = 0.037). The authors concluded that there are steeper biceps tendonglenoid angles in patients with biceps tendon subluxation, though the finding does not appear to be clinically relevant.

    Figure A depicts an axial T2 MRI image with medial subluxation of the biceps tendon. Illustration A is a diagram showing various types of biceps tendon subluxation.

    Incorrect answers:

    Answer 1: Disruption of the anterior inferior glenohumeral ligament has not been associated with biceps tendon subluxation. This injury typically occurs after shoulder dislocations.

    Answer 3: Superior labral tears have not been associated with medial biceps tendon subluxation. Answer 4: Infraspinatus tendon tears have not been associated with medial biceps tendon subluxation.

    Answer 5: Posterior labral tears can occur following posterior shoulder dislocations, but have not been associated with biceps tendon subluxation.

     

     

     

     

18. A collegiate waterpolo player presents to your office for a second opinion. He has had 2 anterior dislocations of his throwing shoulder, both of which were able to be reduced on the pool deck. However, he feels the shoulder is still unstable and cannot return to play at his desired level. Which of the below factors places him at greatest risk for recurrent dislocation following isolated arthroscopic labral repair?

     

     

     

     

     

    Instability of dominant arm Overhead throwing athlete Age under 25 years

     

     

    Labral tear involving the biceps attachment

     

     

    An inverted pear-shaped glenoid on arthroscopy

    CORRECT ANSWER: 5

    Of the options available, severe glenoid bone loss (>25%) leading to an inverted-pear shape greatly increases the risk of recurrent instability with labral repair.

    Many factors come in to play in managing anterior shoulder instability. Initial treatment historically involved isolated Bankart repairs/capsulorraphy but high rates of failure were seen in certain patient demographics. This led to the reemergence of open bony augmentation procedures which have been shown to reliably stabilize the glenohumeral joint. Though there is no consensus regarding indications for these procedures, significant glenoid bone loss (>2025 %) has been frequently cited as such. Additionally, humeral bone loss creating an off-track lesion is also a relative indication.

    These factors (glenoid and/or humeral bone loss) in combination with generalized ligamentous laxity, patients under 20 years old, patients participating in contact sports and at a competitive level, were cited as independent risk factors for recurrent instability by Boileau et al., and were used to synthesize their Instability Severity Index Score (ISIS).

    Harris et al. reviewed long-term outcomes following arthroscopic compared to open Bankart repair. They found no difference in recurrence rates but open repairs returned to sports more commonly.

    Patient-reported outcomes and rates of arthritis were similar between the two groups as well. Mologne et al. reported a series of 21 active duty service members undergoing isolated arthroscopic labral repair with 25% glenoid bone loss. By 34 months, 9.5 % experienced recurrence instability with 4.5% requiring revision surgery. This limited series shows that isolated labral repair may stabilize a glenoid deficient shoulder in the short-term.

    Illustration A is a sagittal MRI sequence demonstrating an inverted-pear glenoid. Incorrect answers:

    Answer 1- There is no added risk of recurrence between dominant and nondominant arms. Answer 2- Overhead sports place the shoulder in the common position of dislocation but don't pose an increased risk of instability following stabilization.

    Answer 3- Age under 20 years, not 25, increases risk for recurrent instability. Answer 4- Labral tears may extend superiorly and involve biceps anchor but don't pose increased risk for recurrent instability.

     

     

     

     

19. A 27-year-old volleyball player complains of worsening right posterolateral shoulder pain and weakness for the past 4 weeks. She denies any injury to the shoulder. Her examination reveals 5/5 muscle strength with shoulder elevation, abduction and internal rotation. She is found to have weakness in external rotation with the elbow at the side and gross inspection is remarkable for mild atrophy along the posterior scapula. She has an unremarkable lift-off test. Which nerve and corresponding site of compression is most likely responsible?

     

     

     

     

     

     

     

     

     

    Suprascapular nerve and Suprascapular notch Axillary nerve and Quadrilateral space Suprascapular nerve and Spinoglenoid notch Upper subscapular nerve and Spinoglenoid notch Radial nerve and Triangular interval

    CORRECT ANSWER: 3

    This clinical scenario is suggestive of infraspinatus muscle weakness due to suprascapular nerve compression at the spinoglenoid notch.

    Both the supraspinatus and infraspinatus are innervated by the suprascapular nerve. This nerve emerges off the superior trunk (C5,C6) of the brachial plexus. At the scapula, it traverses through the suprascapular notch beneath the suprascapular ligament to innervate the supraspinatus muscle and continues distally through the spinoglenoid notch to innervate the infraspinatus muscle.

    Compression proximally at the suprascapular notch would result in both supraspinatus and infraspinatus weakness. In this vignette, only the infraspinatus appears to be involved as demonstrated with weakness in external rotation with the arm at the side and posterior scapular atrophy.

    Safran et al. explains that while isolated suprascapular nerve injuries are uncommon, they remain the most frequently injured peripheral branch of the brachial plexus in athletes. Suprascapular nerve palsies should be considered in throwing athletes and those athletes exposed to repetitive trauma, such as baseball players, tennis players, weight lifters, swimmers, and volleyball players. Piasecki et al. discusses how traction neuropathy may occur following excessive nerve excursion with overhead sports or as the result of a massive, retracted rotator cuff tear in older patients. He further discusses surgical treatment following failed conservative management, and reports that surgery provides reliable pain relief with improvements in function. However, return of strength and muscle bulk is less predictable.

     

     

    nerve entrapment. Electrodiagnostic studies are often helpful in making the diagnosis. MRI and ultrasound are useful in demonstrating ganglion cysts, muscle atrophy and associated labral pathology. The mainstay of treatment remains conservative management with activity modification, anti-inflammatory medication, and periscapular muscle strengthening. Surgical intervention is merited when there is no improvement after 6 months of conservative management. Illustration A:

    Demonstrates the course of the suprascapular nerve with potential compression sites occurring at the suprascapular and spinoglenoid notches

    Incorrect Answers:

    Answer 1: This patient demonstrates no supraspinatus weakness. Therefore, compression of the suprascapular nerve must be after innervation to the supraspinatus.

    Answer 2: Compression of the axillary nerve in the quadrilateral space will often demonstrate weakness with forward elevation and abduction. Answer 4: The upper and lower subscapular nerves innervate the subscapularis muscle. This muscle contributes to internal rotation of the shoulder and may be tested with the lift-off test. Additionally, the subscapular nerve does not traverse the spinoglenoid notch.

    Answer 5: The radial nerve runs through the triangular interval along with the profunda brachii artery in the posterior compartment of the arm. Compression of this nerve will demonstrate weakness with elbow and wrist extension.

     

     

     

     

     

20. An 18-year-old football linebacker reports persistent left shoulder pain for the past 3 months. He complains of a feeling of instability and an inability to perform a bench-press or push-up. He has a positive posterior jerk and Kim test. Radiographs show no fracture and the shoulder is shown to be well-located on the axillary view. Which of the following acts as the primary restraint to posterior displacement of the shoulder in the position of flexion and internal rotation?

     

     

     

     

     

    Anterior band of the inferior glenohumeral ligament Middle glenohumeral ligament

     

     

    Anterior labrum

     

     

     

     

    Posterior band of the inferior glenohumeral ligament Superior glenohumeral ligament

    CORRECT ANSWER: 4

    This patient has symptoms of posterior shoulder instability. The posterior band of the inferior glenohumeral ligament (IGHL) is the most important restraint to posterior subluxation at 90 degree of shoulder flexion and internal rotation.

    Posterior instability often occurs in young athletes who perform activities with the shoulder in a flexed, adducted, and internally rotated position. Football lineman receive repetitive microtrauma from a posterior force to the upper extremity while performing a block in this position. This ultimately lends the shoulder to develop symptoms of posterior shoulder instability. The IGHL is a triangular structure that extends between the glenoid labrum, triceps tendon and subscapularis muscle. Unlike the dynamic stabilizers of the shoulder such as the rotator cuff, which serve an important role in concavity compression, the glenohumeral ligaments serve a vital function in static stability. At 90 degrees of forward elevation and with the arm in an internally rotated position, the posterior band of the IGHL resists posterior translation of the humerus. Of note, other patients who are prone to posterior shoulder instability are those with ligamentous laxity or excessive glenoid retroversion.

    Millett et al. discusses the difficulty with making the diagnosis of posterior shoulder instability as the primary complaint is typically pain and not instability. The spectrum of posterior shoulder instability is wide and encompasses unidirectional, multidirectional, and locked instability.

    Conservative management is often successful with most cases of posterior shoulder instability, however surgical management is reserved for refractory cases.

    Kido et al. and Lee et al. discusses the role of the deltoid muscle as an important dynamic anterior stabilizer of the glenohumeral joint with the arm in abduction and external rotation. They demonstrate that the deltoid generates significant shear and compressive force in the position of anterior shoulder instability. Strengthening of the mid and posterior heads of the deltoid with

    anterior shoulder instability provide stability by providing greater compressive force and lower shear force than the anterior head.

    Figure 1 is an axillary radiograph demonstrating a concentric glenohumeral joint. Incorrect Answers:

    Answer 1: The anterior band of the inferior glenohumeral ligament is the primary restraint to anterior and inferior translation of the 90-degree abducted shoulder and maximum external rotation (ie. late cocking phase of throwing). Answer 2: The middle glenohumeral ligament is a restraint to anterior and posterior translation at midrange (~45 degrees) of shoulder abduction in external rotation.

    Answer 3: The anterior labrum serves an important static constraint to anterior translation of the shoulder. The anterior band of the IGHL anchors into the anterior labrum and predisposes to Bankart lesions.

    Answer 5: The superior glenohumeral ligament is a restraint to inferior translation of the adducted shoulder.

     

     

21. A 17-year-old offensive lineman presents with acute on chronic right shoulder pain. His season is nearly complete but the pain began months prior as he increased his pre-season weightlifting regimen, emphasizing the bench press and similar lifts. Pain has persisted since then and now bothers him constantly, and is exacerbated when blocking oncoming defenders. On exam, his right shoulder pain is easily reproduced and now with a palpable clunk. What finding would you expect to see on his MRI and what is the best surgical procedure to address this?

     

     

     

    Antero-inferior labral tear; arthroscopic labral repair Posterior labral tear; arthroscopic labral repair

     

     

    Posterior labral tear; arthroscopic thermal capsulorraphy

     

     

     

     

    Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic labral debridement versus repair Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic biceps tenodesis

    CORRECT ANSWER: 2

    This presentation is classic for a posterior labral tear with instability and would best be treated with an arthroscopic labral repair.

    Posterior instability is far less common than anterior instability. Etiology of instability may vary, but the most common is attritional damage from repetitive microtrauma. As such this is commonly encountered among football linemen, rugby players, and swimmers who experience posterior load to the shoulder. The common denominator between these is frequently loading a shoulder in the forward flexed and internally rotated position, stretching the posteroinferior glenohumeral ligament (PIGHL). Physical exam maneuvers that reproduce this mechanism will cause pain. A variety of pathology may be encountered including simple capsulolabral separation (Reverse Bankart), reverse HIll-Sachs lesions, and paraglenoid cysts.

    Provencher et al. reviewed the diagnosis and management of posterior instability. They note posterior instability is often difficult to diagnose as symptoms may be vague and patients may describe pain with a bench press, push-ups, or a decrease in athletic performance. Though physical exam findings may be subtle, they described the Jerk maneuver, which can re-create the instability episode and aid in diagnosis.

    Bradley et al. conducted a prospective study of contact versus non-contact athletes following arthroscopic posterior labral repair for recurrent instability. There was no difference between the two groups in terms of recurrence or patient-reported outcomes. Additionally, the overall rate of return to sport was 89%, with 67% returning to play at the same level.

    Illustration A demonstrates the Jerk test, which is performed by placing an axial force onto the patient's shoulder which is forward flexed, abducted, and internally rotated. Illustration B is an axial fluid sensitive MRI demonstrating a posterior labral tear (in addition to an anterior labral tear).

    Incorrect answers:

    Answer 1- This is describing the classic Bankart lesion in the setting of anterior instability. Answer 3- Thermal capsulorraphy is not performed due to iatrogenic chondral damage.

    Answers 4 and 5- While SLAP tears can be seen, the history and exam findings would be different.

     

     

     

     

     

     

     

22. A 19-year-old collegiate pitcher presents to your clinic with a right shoulder injury he sustained 6 weeks prior while sliding into a base.

    He endorses pain and weakness of the right shoulder, especially while bench pressing. Physical examination reveals a positive Kim's test, a negative O'Brien's test, and normal rotator cuff strength. Radiographs are unremarkable. MRI confirms the suspected injury without any evidence of bony abnormalities. The patient would like to proceed with surgical

    treatment. What is the most likely complication after the appropriate surgical treatment for this patient?

     

     

     

     

     

    Posterior instability Anterior instability Suprascapular neuropraxia

     

     

     

     

    Decreased internal rotation Glenohumeral joint arthritis.

    CORRECT ANSWER: 4

    The patient has clinical signs and symptoms of a posterior labral tear (positive Kim test, shoulder pain with bench pressing). The operative treatment of this injury would be a posterior labral repair and post-operative stiffness with a decreased range of motion are the most common complication after this procedure.

    Management of posterior labral tears can be non-operative or operative. Nonoperative treatment comprises of a brief period of immobilization following by PT. Often times, a corticosteroid injection can help with significant pain relief as well. Patients with continued pain despite PT, in the absence of bony defects or glenoid abnormalities, should undergo arthroscopic repair of the posterior labrum. Following posterior labral repair, patients are generally placed in a shoulder immobilizer in neutral rotation for as much as 6 weeks depending on the size of the tear before beginning any significant active and passive range of motion. As such, the most common postoperative complication is stiffness due to immobilization and scar tissue formation. In addition to stiffness, other complications following posterior labral repair include posterior instability, degenerative joint disease, and axillary/suprascapular nerve neuropraxia.

    Millett et al. reviewed the etiology and management of recurrent posterior shoulder labral tears. They discuss initial nonsurgical treatment with physical therapy which is successful in the majority of cases but note that surgical treatment is indicated when conservative treatment fails. They state that for the best results, the surgeon must accurately define the presence of instability and address all soft-tissue and bony injuries present at the time of surgery.

    Hawkins et al. assessed the degree of radiographic glenohumeral translation in a series of anesthetized patients which were broken down into a control group (18 patients), 10 patients with anterior instability, and 10 patients with multidirectional instability (MDI). The authors noted significant differences in resting anterior translation, posterior translation and inferior translation between controls, and those with symptoms of anterior instability and MDI. The authors conclude that the most optimal method to grade translation of the humeral head within the glenoid involves assessment of where the center of the humeral head lies in reference to the glenoid rim.

    Kido et al. performed a cadaveric study on 9 fresh shoulders to determine the contribution of the deltoid muscle to anterior stability of the shoulder. The authors noted that with the capsule intact, anterior displacement was significantly reduced by the application of load to the middle deltoid muscle. The authors concluded that the deltoid muscle is an anterior stabilizer of the glenohumeral joint with the arm in abduction and external rotation.

    Lee and An evaluated the 3 heads of the deltoid as dynamic stabilizers of the glenohumeral joint. The authors noted the deltoid provided increased stability with the arm in the scapular plane and only decreased the stability of the shoulder with the arm in the coronal plane. The authors concluded that the middle and posterior heads of the deltoid should be strengthened in anterior shoulder instability in both conservative and operative treatment because they provide more stability, generate higher compressive force, and lower shear forces than the anterior head.

    Incorrect Answers:

    Answer 1: Posterior instability is the 2nd most common complication after posterior labral repair for posterior shoulder instability.

    Answer 2: Anterior instability would not be expected after posterior labral repair for posterior shoulder instability.

    Answer 3: Suprascapular nerve (and axillary nerve) neuropraxia may happen after posterior labral repair for posterior shoulder instability, but this is not as common as shoulder stiffness.

    Answer 5: Degenerative joint disease is the 3rd most common complication after posterior labral repair for posterior shoulder instability.

     

     

23. A 28-year-old Olympic water polo athlete complains of vague medial sided elbow pain that has progressively worsened with a noticeable loss of velocity on his shot. Which of the following correctly matches the throwing phase (Figure A) with the injured structure on the MRI (Figure B).

     

     

     

     

     

     

     

     

     

    B and 2

     

     

    C and 2

     

     

    B and 3

     

     

    D and 1

     

     

    C and 3

    CORRECT ANSWER: 2

    This athlete has symptoms of chronic ulnar collateral ligament (UCL) attrition with the increasing pain and loss of shot velocity. The greatest loads on the UCL are seen in the late cocking phase of throwing (C). The UCL is correctly depicted by number 2 on the coronal MRI image. This makes the correct answer number 2 (Phase C and Number 2).

    The ulnar collateral ligament (UCL) is composed of three parts. The anterior bundle, posterior bundle, and the transverse bundle. The Anterior bundle, which is the primary restraint to valgus stress, can be further divided into anterior and posterior bands. The anterior band of the anterior bundle is the primary restraint from full extension to 85 degrees of flexion. While the posterior band is taught beyond 55 degrees. The posterior bundle functions with the elbow flexed beyond 90 degrees. Other restraints to valgus forces on the elbow include the Flexor Carpi Ulnaris (FCU), the Flexor Digitorum Superficialis (FDS), and the radiocapitellar joint. Chronic repetitive stress on the UCL by overhead athletes has significant effects on the medial, lateral and posterior aspects of the elbow joint. Ultimately, athletes can complain of loss of velocity, loss of "zip" in their throw, medial sided elbow pain, paresthesias in the ulnar nerve distribution of the hand, and instability.

    History and physical examination are important. Physical examination maneuvers such as valgus stress to the elbow with the elbow flexed approximately 30 degrees, Milking Maneuver and moving valgus stress test are important tests. MRI is the mainstay for imaging. Surgical treatments vary from primary repair to complete reconstruction.

    Safran et al. in 2005 reviewed the current concepts of the Ulnar Collateral Ligament of the Elbow. In that article, he discussed the pertinent anatomy, biomechanics, pathophysiology, diagnosis, and treatment of UCL injuries. The AOL is considered to be the most important contributor to valgus stress resistance in the elbow with contributions from FCU, FDS, and the radiocapitellar joint.

    Chronic stress to the UCL can lead to rupture or attrition of the ligament with effects on the lateral and posterior aspect of the elbow joint. The moving valgus stress test has been shown to be the most sensitive physical examination maneuver to identify UCL injury. They further discussed the treatment of UCL injuries. Ultimately, Safran et al. determined that overhead athletes place significant load on the medial side of their elbow that can lead to attrition and/or rupture as well as deleterious effects throughout the elbow joint and that treatments are more than surgical correction alone, but also needs to address the root cause.

    Safran in 2003 reviewed the diagnosis and treatment of UCL elbow injuries. In his article, he discussed the anatomy, biomechanics, pathophysiology, diagnosis, and treatment of UCL injuries. Important physical examination maneuvers include a valgus stress test of the elbow at 30 degrees of flexion, the milking maneuver, and the moving valgus stress test. Initial treatment is conservative and surgical options were discussed that include reconstruction with either allograft or autograft and different tunnel techniques were described along with their outcomes.

    Erickson and Romeo reviewed UCL injuries. They discussed the pertinent anatomy, evaluation, and treatment of these injuries. The risk factors and use of prevention programs were discussed.

    Surgical treatments were discussed including primary repair of the UCL with either proximal or distal lesions and use of the docking technique with their technique described. They discussed concomitant ulnar nerve pathology and using a subcutaneous transposition for those with symptoms.

    Figure A is a cartoon image that depicts the different throwing phases. A is the wind phase. B is the early cocking. C is the late cocking. D is the acceleration and E is the deceleration phase.

    Figures B and C are coronal MRI slices of an elbow. Number 1 identifies FlexorPronator Origin. Number 2 is the Ulnar Collateral Ligament (UCL) and Number 3 is the Radial Collateral Ligament. Incorrect Answers:

    Answer 1: Phase B is the early cocking phase, which does not put the most stress on the UCL. Number 2 does correctly identify the UCL on the MRI. Answer 3: Phase B is the early cocking phase, which does not put the most stress on the UCL. Number 3 is not the UCL. Rather it identifies the radial collateral ligament.

    Answer 4: Phase D is the acceleration phase, not the late cocking phase. Number 1 is the flexor-pronator origin, not the UCL.

    Answer 5: Phase C is the late cocking, but number 3 is the radial collateral ligament.

     

     

24. A 44-year-old male sustains the injury shown in Figures A and B. Which of the following

statements is true in regards to the treatment for the injury depicted?

 

 

 

 

 

1 . Non-surgical management results in improved strength and range of motion 2 . The most common complication related to surgical management is an injury to the terminal branch of the musculocutaneous nerve 3 . Surgical fixation with bone tunnels offers the weakest repair

 

 

Surgical fixation with a cortical button offers the strongest repair

 

 

Synostosis is the most common complication following a single-incision surgical approach

CORRECT ANSWER: 2

He has suffered a distal biceps rupture as depicted in selected MRI slices ( Figures A and B). The most common complication of this surgery is an injury to the lateral antebrachial cutaneous nerve (LABCN), which is the terminal branch of the musculocutaneous nerve.

Distal Biceps injuries are more common in males in their 40s. Non-operative management for complete ruptures is usually reserved for older and lowdemand individuals as there is a loss of

sustained supination and flexion strength. Operative management is the mainstay of treatment through either a single or two-incision approach. The most common complication related to both the single and two-incision surgical technique is an injury to the LABCN. The two-incision surgical technique has an increased risk of synostosis and heterotopic ossification when compared to the single-incision surgical technique. The most biomechanical strong fixation is with use of both a cortical button and an interference screw.

Chavan et al. performed a systematic review that focused on distal biceps fixation, surgical approach, and complication profile. They found that the cortical button was biomechanically superior to all other methods of surgical fixation and there was not any significant difference in complications between single and two-incision techniques. However, the two-incision group had greater unsatisfactory clinical results that were defined by loss of range of motion of >30 degrees in any plane and/or loss of strength of <80% in flexion or supination.

Peeters et al. completed a retrospective case series with 26 patients that underwent distal biceps repair using cortical button fixation. At 16 months of average follow-up, patients had excellent function and improved pain, and the average flexion strength at the elbow was 80% and the average supination strength was 91%. Two patients had asymptomatic heterotopic ossification, three patients had their cortical button disengaged and one required removal. The authors concluded that the surgical fixation using a cortical button for distal biceps reattachment allows for excellent and reproducible clinical results.

McKee et al. reported their outcomes on 53 patients that completed a patientoriented outcome questionnaire following single-incision distal bicep repair using two suture anchors. This single

 

 

similar to the mean DASH score in population controls, 6.2. Complications included one wound infection, two transient neuropraxic LABCN injuries and one posterior interosseous transient nerve palsy. There was not any loss of surgical fixation following repair and all patients had returned to within 5 degrees of their presurgical range of motion at the elbow.

Figures A and B are sagittal and axial T2 MRI slices, respectively, that demonstrate a complete distal biceps rupture with disruption of the tendon insertion to the radial tuberosity and the surrounding edema.

Incorrect Answers:

Answer 1: Non-surgical management of complete distal bicep ruptures does not result in improved strength and range of motion. Non-surgical management will lead to approximately a 50% loss of sustained forearm supination strength and approximately a 40% loss of sustained elbow flexion strength.

Answer 3: Distal biceps repair using bone tunnels is not the most biomechanically inferior technique. Surgical repair using a single interference screw is the most biomechanically inferior method.

Answer 4: Surgical repair using a cortical button alone does not result in the greatest time-zero biomechanical strength. The greatest time-zero biomechanical surgical fixation strength is obtained with the combination of the cortical button and interference screw.

Answer 5: The most common complication related to both the single and twoincision surgical technique is an injury to the LABCN.

 

 

67 ) A 47-year-old former professional wrestler is helping his friend move some furniture. A large sofa slips from the patient's grip, which causes his elbow to extend. He feels a pop and develops ecchymosis about his antecubital fossa. He discusses his care with a hand surgeon who recommends surgical repair, but the patient is reluctant. Conservative management of this pathology has been shown to result in all of the following EXCEPT?

 

 

 

 

 

 

 

 

 

 

 

Lateral antebrachial neuritis Loss of supination strength Loss of supination endurance Loss of flexion strength Delayed return to activities

CORRECT ANSWER: 1

Surgical repair is advocated for distal biceps ruptures in most cases, as patients treated conservatively experience deficits in supination strength, supination endurance, flexion strength, and experience a delayed return to activities. However, neuropraxia of the lateral antebrachial cutaneous nerve ( LABCN) is exclusively associated with surgical management.

Distal biceps ruptures often present with antecubital ecchymosis, proximal muscle retraction, and a positive "hook test." A "reverse Popeye" deformity is often apparent. Physical exam is most notable for loss of supination strength, and to a lesser extent decreased flexion strength due to the contribution from the brachialis. Non-operative management is an option most frequently reserved for low-demand individuals. Surgery is generally recommended for complete ruptures. Injury to the LABCN is the most common complication of surgical repair.

Sutton et al. comprehensively reviewed distal biceps ruptures. The authors noted that these injuries typically occurred in men aged 40-49 and were sustained during eccentric contraction. Degenerative changes and decreased vascularity further put the tendon at risk for rupture. The authors advocated for surgical management as non-operative treatment resulted in a significant loss of supination strength. However, the risks of surgical management included neuropraxia, infection, and heterotopic ossification. The authors emphasized that surgical management furthermore allowed for earlier return to activity.

Baratz et al. also reviewed distal biceps ruptures. The authors emphasized the consequences of nonoperative management, which included a 30-50% loss of supination strength, and a 30% loss of flexion strength. They highlighted one study in particular which allowed for range of motion 1-2 days after repair and a second in which patients averaged 111% of supination strength postoperatively. The authors advocated for early repair (within 2 weeks) and early range of motion (2-5 days post-operatively).

Figure A is an axial cut of the proximal forearm (T2 sequence). The edema around the radial tuberosity indicates a biceps avulsion injury.

Incorrect answers:

Answer 2: Non-operative management may result in a loss of 40% of supination strength.

Answer 3: Non-operative management may result in a loss of 50% of supination endurance. Answer 4: Non-operative management may result in a loss of 30% of flexion strength.

Answer 5: Non-operative management may result in a singingly greater delay in returning to activities.

 

 

1. A 13-year-old male left-hand dominant tennis player presents to your clinic with left shoulder pain. He states that he has diffuse shoulder pain on the left side and he is unable to control his serves when playing tennis. Your exam is notable for tenderness to palpation at the proximal left arm. You note that he has a measured difference in internal rotation between the affected shoulder and contralateral shoulder to be 30 degrees. You diagnose him with Little League shoulder. Which radiographic view can aid in the diagnosis in subtle cases?

    

    

    

    

    

   Distal humeral axial West Point axillary Zanca

    

    

    

    

   Shoulder AP in external rotation Swimmer's

   CORRECT ANSWER: 4

   An AP radiograph of the affected shoulder with external rotation at the shoulder will help facilitate the diagnosis. The radiographic findings in the physis are most clearly identifiable in the anterolateral physis of the proximal humerus.

   Little League Shoulder (LLS) is an overuse condition that is commonly seen in the dominant arm of skeletally immature athletes. It is most commonly seen in pediatric baseball pitchers but can be present for youths in other overhead sports (e.g. tennis, football, racket sports) as well. Due to the repetitive microtrauma (shear, torque, or traction forces) imposed on the unossified cartilage of the proximal humeral physis, the patient will typically complain of diffuse shoulder pain with or without throwing and/or loss of control with throwing or decrease performance in their given sport. Classic radiographic findings include physeal widening, increased sclerosis, demineralization/lucency, metaphyseal calcification, or fragmentation adjacent to physis. AP radiographs in external rotation and/or radiographs of the contralateral shoulder can aid in the diagnosis. The majority of patients have a resolution of LLS with conservative management in the form of time away from their sport. Those with glenohumeral internal rotation deficits (GIRD) have an increased probability of recurrence of LLS.

   Heyworth et al. performed a retrospective case series on LLS to analyze the demographic and diagnostic features and to identify risk factors for occurrence. They analyzed 95 patients with LLS. The most common demographic was male pitchers with an average age of 13.1 years. They additionally identified LLS in female athletes. The authors reported resolution of symptoms and return to competition on average was 2.6 months and 4.2 months, respectively. The overall recurrence rate was 7% and those diagnosed with GIRD had 3.6 times greater odds of recurrence. Harada et al. completed a retrospective case-control study of 87 skeletally immature baseball players diagnosed with LLS. At 2 months follow-up, 18% still had pain, 43% had completed return to sport (RTS), 33% had incomplete RTS, and 24% did not have any RTS. They concluded that a longer time to diagnosis and those with GIRD were risk factors for continued pain and recurrence of LLS.

   Incorrect Answers:

   Answer 1: A distal humeral axial view is used aid in measuring the displacement in pediatric fractures of the medial epicondyle.

   Answer 2: A West Point axillary view is an additional shoulder view that can identify a bony bankart and associated glenoid bone loss.

   Answer 3: A Zanca view is an AP of the shoulder with 15 degrees cephalic tilt that is used in acromioclavicular joint pathology.

    

   ral view obtained when a normal lateral view of the cervical spine does not have all 7 cervical vertebrae visible.

    

    

    

2. A 42-year-old man is performing his final deadlift at the annual CrossFit games when he suddenly experiences severe pain in his right arm and is unable to continue. Physical examination is significant for medial brachial ecchymosis, swelling and tenderness over the antecubital fossa, and significantly diminished supination strength. Radiographs are unremarkable and an MRI is shown in Figure A. Given his age and activity level, he is taken for primary surgical repair utilizing a single-incision technique with combined cortical button and interference screw fixation. When the patient returns to clinic, he is found to have experienced the most common neurologic complication associated with this procedure. What is the course of the affected nerve?

    

    

    

   Branches distal to the elbow, passing between two heads of pronator teres, running along volar aspect of the flexor digitorum profundus

    

    

   Dives through the supinator, coursing around the radial neck within the deep compartment of the forearm

    

    

   Pierces the fascia of the biceps brachii and lays lateral to biceps tendon, deep to the cephalic vein, until emerging and running superficially along the brachioradialis

    

    

   Runs deep to the brachioradialis and lateral to the radial artery, piercing the fascia of the brachioradialis and becoming superficial within the distal forearm 5 . Runs with brachial artery where it enters the forearm between the pronator teres and biceps tendon, traveling between the flexor digitorum superficialis and profundus

   CORRECT ANSWER: 3

   The most common neurologic complication and most common complication overall is neuropraxia of the lateral antebrachial cutaneous (LABCN). The LABCN pierces the fascia of the biceps brachii and lays lateral to the biceps tendon, deep to the cephalic vein, until emerging and running superficially along the brachioradialis.

   Distal biceps tendon ruptures are uncommon but often debilitating injuries in younger active individuals. Surgical management is often recommended for patients with complete tears and chronic symptomatic partial tears due to persistent deficits most notably in supination and to a lesser extent in elbow flexion strength. The two most commonly used approaches are the single-and dual-incision repair, with a gamut of repair techniques. The advantages and disadvantages of each approach are somewhat controversial, however, it is agreed upon that surgery reliably restores function with minimal risk of serious complications. The most common surgical complication is transient LABCN neuritis, cited in nearly one-quarter of cases and more common with the

   singleincision approach. Injury to the superficial branch of the radial nerve ( SBRN), posterior interosseous nerve (PIN), median nerve, or anterior interosseous nerve (AIN) are increasingly rare, in that order. Heterotopic ossification is more common with a dual-incision approach, though the relative risk of PIN palsy remains disputed.

   Cain et al. reviewed 198 consecutive cases of distal biceps tendon repair. The authors reported an overall 36% complication rate, with 3% requiring reoperation. The most common minor complications were LABRN neuritis (26%) and SBRN neuritis (6%), while major complications included PIN palsy (4 %) and symptomatic heterotopic ossification (3%). The authors concluded that despite the high complication rate, most were transient neuropraxias, but cautioned about an increased rate of complications in surgeries performed over 28 days after injury.

   Grewal et al. compared outcomes of the single- to the dual-incision technique for distal biceps repairs. The authors found that there were no significant differences at two-year follow-up in rate of recovery or any of the functional outcome scores, though dual-incision was associated with 10% greater isometric flexion strength. The authors concluded that the rate of complications was significantly greater in the single-incision group, but most often due to transient LABCN neuropraxia (40% vs 7%).

   Cohen reviewed the complications associated with distal biceps tendon repairs. The author highlighted the importance of surgical repair and noted that small differences between techniques were often clinically negligible as most patients returned to near full upper extremity function regardless. He noted that the single-incision repair was associated with less risk of heterotopic ossification, but carried a greater risk of neurologic injury, the most common being LABCN neuropraxia and to a much lesser extent PIN palsy.

   Figure A is a sagittal T2 MRI cut demonstrating a complete distal biceps tendon rupture with proximal retraction.

   Incorrect Answers:

   Answer 1: The anterior interosseous nerve branches from the median nerve within the forearm, 58cm distal to the lateral epicondyle, passes between two heads of pronator teres, runs along volar FDP, and ends in pronator quadratus at wrist.

   Answer 2: The PIN branches from the radial nerve at the level of the radiocapitellar joint, dives through the supinator Arcade of Froshe, courses around the radial neck, emerges within the deep compartment of the forearm, and ends in the dorsal wrist capsule.

   Answer 4: The SBRN branches from the radial nerve at the level of the radiocapitellar joint, runs deep to the brachioradialis and lateral to the radial artery, and pierces the fascia of the forearm 79cm proximal to the wrist where it courses to supply sensation over the snuffbox and dorso-radial hand. Answer 5: The median nerve runs with brachial artery where it enters the forearm between the pronator teres and biceps tendon, and travels between the flexor digitorum superficialis and profundus until emerging between flexor digitorum superficialis and flexor pollicis longus distally and entering the carpal tunnel.

    

    

3. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. His pain is aggravated when grappling with other wrestlers and when performing push-ups. He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. Which of the listed structures augments the posterior-inferior glenohumeral ligament and is a static restraint to posterior translation of the humeral head on the glenoid when the shoulder is forward flexed, adducted, and internally rotated?

    

   Supraspinatus

    

    

    

    

   Middle glenohumeral ligament Subscapularis

    

    

    

    

   Superior glenohumeral ligament Anterior-inferior glenohumeral ligament

   CORRECT ANSWER: 4

   The superior glenohumeral ligament augments the posterior-inferior glenohumeral ligament and is a static restraint to posterior translation of the humeral head on the glenoid when the shoulder is forward flexed, adducted, and internally rotated.

   Posterior glenohumeral instability can present in a variety of patient populations and can occur secondary to a traumatic posterior shoulder dislocation or from recurrent posterior subluxations.

    

    

   shoulder forward flexion, adduction, and internal rotation. The stability of the shoulder is achieved through both static and dynamic stabilizers. The static stabilizers include the osseous morphology of the glenoid and humeral head, glenoid labrum, capsule, and glenohumeral ligaments.

   Understanding the respective contributions of each of these structure in the relation to the position of the shoulder in space can aid in identifying the exact location of pain and specific injured structure.

   Bradley et al. review the pathophysiology, diagnosis and management of posterior shoulder instability. They review the anatomical and biomechanical considerations of the shoulder and posterior instability. They noted that the posterior-inferior and superior glenohumeral ligaments function synergistically when the shoulder is forward flexed to 90 degrees, adducted, and internally rotated.

   Kim et al. performed a cohort study that sought to identify the sensitivity and specificity of the Kim test and the jerk test for posteroinferior labral lesions of the shoulder. The sensitivity of the Kim test was 80% and the specificity was 94 %. The sensitivity of the jerk test was 73%% and the specificity was 98%. The Kim test was more sensitive in identifying inferior labral tears and the jerk test was more sensitive in identifying posterior labral tears. When the two tests were both positive there was a sensitivity of 97% for identifying posteroinferior labral tears. Incorrect Answers;

   Answer 1: The supraspinatus muscle is a dynamic restraint of the shoulder and prevents inferior instability.

   Answer 2: The middle glenohumeral ligament is a static restraint of the shoulder to anterior and posterior translation with shoulder at 45 degrees of abduction.

   Answer 3: The subscapularis muscle is a dynamic restraint of the shoulder to posterior translation when the shoulder is externally rotated.

   Answer 5: The anterior-inferior glenohumeral ligament is a static restraint of the shoulder to anterior translation with the shoulder abducted to 90 degrees and externally rotated.

    

    

4. A 55-year-old male presents to your clinic after a fall off a ladder and landing on his left shoulder. On examination, he has a positive drop arm sign but full passive, but painful, range of motion of the left shoulder. Radiographs are shown in Figures A and B. MRI studies are obtained and shown in Figures C through E. The patient elects to undergo operative intervention. Which of the following is true with respect to a double-row rotator cuff repair compared to a single-row repair?

    

    

    

    

    

   Increased time to healing with double-row repair compared to single-row repair

    

    

    

    

   Decreased functional outcome scores with single-row repair compared to double-row repair Decreased re-tear rate with double-row repair compared to single-row repair

    

    

    

    

   Increased post-operative pain with double-row repair compared to singlerow repair Less anatomic footprint restoration with a double-row repair compared to a single-row repair

   CORRECT ANSWER: 3

   The patient in the vignette has a large left rotator cuff tear. There is a lower retear rate associated with double-row rotator cuff repair (RCR) versus a single-row RCR.

   There are many important and controversial topics with respect to arthroscopic rotator cuff repair. One important concept is the restoration of the rotator cuff footprint during the repair. It has been cited that a larger footprint will improve healing and the mechanical strength of the rotator cuff repair. A double-row suture technique (with mattress sutures in the medial row and simple sutures in the lateral row) has been shown to create a more anatomic repair of the footprint leading to a lower incidence of retears compared to a single-row repair (medial row mattress sutures only).

   However, there has been no difference noted between the techniques with respect to functional outcome scores, pain scores, or time to healing.

   DeHaan et al. performed a systematic review of prosepective level I or II studies that compared the efficacy of single-row RCR versus double-row RCR. The authors found that the functional ASES, Constant, and UCLA outcome scores revealed no difference between the 2 groups. The authors did note that the total retear rate, which included both complete and partial re-rears, was 43.1 % for the single-row RCR and 27.2% for the double-row RCR (P = .057). The authors concluded that

   double-row RCR revealed a trend toward a lower radiographic proven re-tear rate, although the data did not reach statistical significance.

   Millett et al. performed a systematic review and meta-analysis of level 1 randomized trials comparing single-row with double-row RCRs to compare clinical outcomes and imaging-diagnosed re-tear rates. The authors reviewed 7 studies that met their inclusion criteria and noted there were no significant differences in ASES, UCLA, or Constant scores between the single-row and doublerow groups. They did note that there was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group compared to the doublerow group. The authors concluded that single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears.

   Figures A and B are the Grashey and axillary lateral radiographs of the left shoulder without any definitive pathology. Figures C, D, and E are the sagittal T2 weighted MRI sequences showing a full-thickness left superior rotator cuff tear.

   Incorrect Answers:

   Answer 1: There is no difference between the time to healing of a double-row RCR versus a singlerow RCR.

   Answer 2: There is no difference between the postoperative functional scores of a patient who has undergone a double-row RCR versus a single-row RCR. Answer 4: There is no difference between the postoperative pain scores of a patient who has undergone a double-row RCR versus a singlerow RCR. Answer 5: A MORE anatomic restoration of the footprint is often cited with a doublerow RCR compared to a single-row RCR.

    

    

5. A 52-year-old male presents to your clinic after injuring his left arm while moving apartments 2 weeks prior. He was helping lift a heavy piano across the floor and suddenly felt a pop in his left elbow.

He has mild pain and swelling around the antecubital fossa.

Radiographs are shown in Figures A and B and MRI studies are shown in Figures C and D. Non-operative management will likely lead to which of the following clinical outcomes?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic elbow instability Chronic elbow pain Decreased supination strength

 

 

 

 

A relative loss of elbow flexion compared to supination Persistent lateral elbow pain with resisted wrist extension.

CORRECT ANSWER: 3

The patient has a left partial distal biceps tendon tear based on the MRI and clinical history. Nonoperative management is most likely to lead to decreased supination strength.

A distal biceps tendon rupture generally occurs due to a sudden excessive eccentric tension as the arm is forced from a flexed to an extended position. These injuries comprise of 10% of all biceps injuries. Partial tears occur primarily on the radial side of the tuberosity footprint. Management is generally operative but patients who are low demand or who have partial injuries can be managed non-operatively. The most common sequela of nonoperative management is a decrease in supination strength compared to the uninjured side.

Bisson et al. performed a retrospective review of 45 consecutive cases of dual incision distal biceps tendon repairs to assess for the incidence of complications. They noted that 12 of 45 patients (27%) experienced a total of 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early re-rupture in 1, and reflex sympathetic dystrophy in 1. They also noted that complications were significantly more common when the repair was performed 2 weeks after the day of injury.

Watson et al. performed a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. The authors found 22 studies looking at 494 patients and cited a 24.5% complication rate with no difference between the single and dual incision approach. The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). The authors conclude that the complication rate does not differ significantly between one and two-incision distal biceps repairs.

Schmidt et al. performed a study to evaluate the pain, disability, and isometric supination torque at 3 forearm positions in a prospective cohort of bicepsdeficient arms to assess the potential for functional return with nonoperative treatment. They studied 23 men with complete unilateral distal biceps avulsion who underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. They found that the uninjured arm was stronger (P <

.001), and peak torque varied with forearm position. They concluded that distal biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm.

Cusick et al. performed a retrospective review of 170 distal biceps ruptures treated using a cortical button in conjunction with an interference screw to evaluate for possible complications. They noted a failure rate of 1.2% with 2 patients requiring a repeat operation. The authors concluded that the use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.

Abrams. et al. performed a cadaveric study to evaluate radial nerve motor branch anatomy within the forearm. The authors looked at 20 normal fresh cadaver arms and noted that the innervation order from proximal to distal ( based on mean shortest branch lengths) was brachioradialis, ECRL, supinator, ECRB, EDC, ECU, EDQ, APL, EPL, EPB, and lastly EIP. They also noted that the mean distances from a point 100 mm proximal to the lateral epicondyle to the muscle measured along the shortest nerve branch ranged from 97.2 mm for the brachioradialis to 299.8 mm for the EIP.

Figures A and B are AP and lateral radiographs of the left elbow which show no findings. Figures C is a T2-weighted axial MRI image that reveals a partial tear of the distal biceps tendon off of the radial tuberosity. Figure D is the T2weighted coronal MRI image also showing a partial tear of the distal biceps tendon with associated fluid around the distal biceps tendon. Illustration A is the labeled version of Figure C which shows the partial biceps tendon tear (red arrow) Incorrect Answers:

Answer 1: Chronic elbow instability would be seen in the event of nonoperative management of a terrible triad injury or anteromedial facet coronoid fracture.

Answer 2: Non-operative management of distal biceps tendon tears are generally not associated with chronic elbow pain.

Answer 4: Non-operative management of distal biceps tendon tears lead to a relative loss of supination compared to elbow flexion.

Answer 5: Persistent lateral elbow pain with resisted wrist extension would be seen with lateral epicondylitis.