9. Shoulder and Elbow MCQs

DISCUSSION: Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head. Staging of the disease is most relevant to prognosis and treatment. Cruess has described a widely accepted staging system. Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V). REFERENCES: Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39. Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. Rutherford CS, Cofield RH: Osteonecrosis of the shoulder. Orthop Trans 1987;11:239. Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999;8:559-564.

DISCUSSION: The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA. RECOMMENDED READINGS: Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283.

DISCUSSION: The blood supply to the adult capitellum and lateral trochlea comes from posterior vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. These arteries penetrate the distal humerus posterior and superior to the capitellum. REFERENCE: Yamaguchi K, Sweet FA, Bindra R, et al: The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79:1653-1662.

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.

Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice. When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief. Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff. Open synovectomy is appropriate in early rheumatoid disease before articular changes are present. Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability.

Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.

The patient has a displaced four-part proximal humerus fracture. The humeral head is displaced and if allowed to heal in this position, the patient will likely have a stiff and painful shoulder. The humerus is at risk for osteonecrosis given the displacement of the fracture. Given a patient age of 82 years, replacement options of either hemiarthroplasty or reverse total shoulder arthoplasty, allow maximal restoration of function. Physical therapy is not indicated in this acute fracture. Closed reduction techniques will not be successful in this displaced fracture.

DISCUSSION: The coracohumeral ligament has been shown to be the primary restraint to inferior translation of the shoulder. Although Bigliani and associates have demonstrated that the inferior capsule and inferior glenohumeral ligaments also play a role, none of the other choices provide primary inferior stability of the shoulder. The coracohumeral ligament is an important structure of the rotator interval of the shoulder (the rotator interval contains the long head of the biceps, the superior glenohumeral ligament, the coracohumeral ligament, and a thin layer of capsule). Harryman and associates demonstrated that an open rotator interval closure via imbrication of the coracohumeral ligament improves inferior stability of the glenohumeral joint.REFERENCES: Harryman DTII, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53 -66.Bigliani LU, Pollock RG, Soslowsky LJ, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.

The patient has an upper plexus palsy (Erb palsy) with severe shoulder contracture. While physical therapy for stretching is the treatment of choice to prevent contracture in the newborn, it is unlikely to be of benefit in the older child with an established contracture. Contracture release alone or in combination with muscle transfers can improve the cosmetic appearance, and in the case of a mild deformity, may also improve function. These procedures are less likely to help when there is deformity of the shoulder joint or when arthritic changes are present. The procedure of choice for an older child with joint deformity is rotational osteotomy of the proximal humerus because it can improve cosmesis and function, even in the face of joint deformity.

The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.

DISCUSSION: Thoracic outlet syndrome is thought to be caused by compression of the neurovascular supply to the upper limb in the supraclavicular and axillary regions of the shoulder. While typically progressive in onset, thoracic outlet syndrome may develop after acute injury. Injury or weakness of the scapular muscles, especially the trapezius, may result in descent of the scapula and cause compression of the thoracic outlet. In general, most symptoms are the result of neural compression. Typical symptoms include pain in the neck or shoulder and numbness or tingling that predominantly involves the ulnar side of the arm and hand. Exacerbation of these symptoms is typical when the arm is abducted. Initial management should consist of postural exercises aimed at restoring proper scapular stability. Severe recalcitrant symptoms may warrant surgical decompression.

DISCUSSION: The patient’s history is typical of patients with severe facioscapulohumeral dystrophy. The scapular winging can be so pronounced that there is significant loss of function of the upper extremity. The surgical options include transfer of the pectoralis major muscle with a tendon graft or scapulothoracic fusion. The latter is a technically demanding procedure but can provide a very stable platform for the upper extremity. Most patients will see increased elevation of the extremity once the scapula is stabilized. Pectoralis minor transfer has not been described and would not be effective.

The patient is presenting with lateral scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy. The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border). Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.

DISCUSSION: The acromial branch of the thoracoacromial artery courses along the medial aspect of the coracoacromial ligament and may be encountered when performing an open or arthroscopic subacromial decompression. Bleeding can be controlled by ligation of its branch from the thoracoacromial artery. The other arteries may be injured in other surgical exposures of the shoulder. REFERENCES: Esch JC, Baker CL: The shoulder and elbow, in Whipple TL (ed): Arthroscopic Surgery. Philadelphia, PA, JB Lippincott, 1993, pp 65-66. Woodburne RT (ed): Essentials of Human Anatomy, ed 2. New York, NY, Oxford University Press, 1983, pp 75-76.

DISCUSSION: Although a recent increase in the number of pitches may have contributed to this patient’s development of little leaguer’s shoulder, the most significant overall factor is age. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress, and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Genetic factors and gender have not been studied in association with little leaguer’s shoulder. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms. Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to baseline pitching is implemented until the patient is back to baseline. This protocol has a long-term success rate exceeding 90%.

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

This patient has moderate glenohumeral arthritis with an irreparable rotator cuff tear. Rotator cuff tears with fatty infiltration are considered to be "irreparable", with arthroscopic repair not indicated as an appropriate option for treatment.The optimal management of patients with irreparable rotator cuff tears with glenohumeral osteoarthritis is not well defined in literature. Initial management should involve conservative measures, including injection of corticosteroids, physical therapy, activity modification, and NSAIDs, with consideration of operative intervention in those that fail a trial of nonoperative management.Laudicina et al review the management of irreparable rotator cuff tears in the setting of glenohumeral osteoarthritis(OA). NSAIDs, corticosteroid injection, activity modification, and physical therapy are mainstays of nonoperative treatment. Failure of conservative management may lead to operative intervention. The authors endorse that hemiarthroplasty is currently the procedure of choice for patients with moderate to severe glenohumeral OA and irreparable cuff tears.Izquierdo et al provide a clinical practice guideline of the treatment of glenohumeral osteoarthritis based on systematic review. Nine of 16 addressed recommendations were inconclusive, illustrating that the management of glenohumeral osteoarthritis remains controversial. The single moderate-rated recommendation was for the use of total shoulder arthroplasty (TSA) rather than hemiarthroplasty. The two recommendations reached by consensus include use of perioperative mechanical and/or chemical DVT prophylaxis for shoulder arthroplasty patients and that TSA should be avoided in patients with glenohumeral OA with irreparable rotator cuff tear.Illustration A demonstrates the Goutallier staging system of rotator cuff tears.Incorrect Answers:

The suprascapular nerve is at risk of injury during anterior-superior anchor insertion for SLAP repair. At the scapular spine level, the suprascapular nerve is approximately 1.5-2.0 cm from the glenoid cortex. This places the nerve at risk of injury during shoulder surgery, and injuries have been described. Arthroscopic SLAP repair is known to be a safe and relatively simple procedure. However, deep drilling or anchor insertion from the anterior or anteriosuperior portal during SLAP repair can place the suprascapular nerve at risk of iatrogenic injury. Morgan et al. performed a cadaveric study to compare the risk of injury to the suprascapular nerve during suture anchor placement in the glenoid when using an anterosuperior portal versus a rotator interval portal. Standard 3 × 14 mm suture anchors were placed in the glenoid rim (1 o’clock, 11 o’clock, and 10 o’clock positions for the right shoulder). They showed that the distance from the far-posterior anchor tip to the suprascapular nerve averaged 8 mm (range, 3.4 to 14 mm) for the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) for the rotator interval portal (P = .001). Koh et al. evaluated the risk of suprascapular nerve injury during the drilling and anchor insertion for anterior SLAP repair. They inserted 1 suture anchor arthroscopically from the anterior portal at 00:30-1:00 o’clock in right shoulders (11-11:30 in left). Using a mean drill depth was 14.2 (±2.8) mm, all suture anchors perforated the glenoid wall and the tips were measured to be approx. 3.1 (±2.7) mm from the suprascapular nerve.

This patient has an isolated supraspinatus rotator cuff tear with symptomatic weakness. The most appropriate treatment is isolated rotator cuff repair. The primary purpose of rotator cuff repair is to restore muscle function. Secondary outcomes include reduction of pain and prevention of irreversible cuff changes, specifically muscular atrophy. Non-operative treatment (exercise, therapy, and pain medications) is recommended for partial-thickness tears. The indication for surgical repair includes isolated supraspinatus weakness that correlates with MRI imaging of a respective full-thickness tear. Routine acromioplasty is not recommended in conjunction with rotator cuff repair, especially with no previous symptoms of impingement. Pedowitz et al. developed clinical practice guidelines for the treatment of rotator cuff pathology. The strongest supporting evidence in current literature was given a grade of 'moderate' with four treatment recommendations: (1) Exercise and non-steroidal anti-inflammatory drugs can be used to manage partial-thickness tears; (2) Routine acromioplasty is not required at the time of cuff repair; (3) Non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage cuff tears; and (4) Surgeons can advise patients that workers' compensation status correlates with a less favorable outcome after rotator cuff surgery.

Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.