9. Shoulder and Elbow MCQs

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful. References: Waters PM: Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 2005;14:233-244. Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am 2005;87:320-325. Moukoko D, Ezaki M, Wilkes D, et al: Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86:787-793.

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. Reference: Simon JA, Puopolo SM, Capla EL, et al: Accuracy of the axillary projection to determine fracture angulation of the proximal humerus. Orthopedics 2004;27:205-207.

Lateral elbow tendinopathy remains a frequently encountered pathology of the elbow. Open or arthroscopic lateral epicondyle debridement can be considered for patients with refractory symptoms. With either technique, the lateral collateral ligament complex of the elbow is at risk for compromise, with excessive debridement distal and posterior to the center of rotation of the capitellum. When injured, patients often complain of pain around the posterior lateral elbow, which is commonly misdiagnosed as recurrent lateral epicondylitis. The push-up test (apprehension using the supinated forearm to push up from a chair) is a typical examination finding, along with a positive posterior drawer test. Patients may also develop posterolateral instability of the elbow, for which the recommended treatment is lateral collateral ligament reconstruction.

The maneuver described is the lateral pivot-shift test, where valgus and axial loads are applied to the extended and supinated forearm while the elbow is gradually flexed. The presence of apprehension in an awake patient suggests posterolateral rotatory instability, indicating insufficiency of the lateral ulnar collateral ligament. Treatment for chronic cases involves reconstruction using a palmaris longus tendon graft combined with plication of the lateral capsuloligamentous structures. Direct ligament repair and isolated plication are less reliable. The long-term effects of thermal shrinkage are still unclear. Because of the failure to respond to nonsurgical management, continued bracing is unlikely to resolve the patient's symptoms.

DISCUSSION: The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery.

DISCUSSION: The trapezius is innervated by the spinal accessory nerve. The nerve is superficial in the area of the posterior cervical triangle and is prone to injury during dissection. Paralysis of the trapezius causes loss of scapular stability when forward flexion or abduction of the shoulder is attempted.

Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate in a patient with pseudoparesis of anterior elevation and external rotation, in the setting of shoulder arthritis (narrowing of glenohumeral joint and acetabularization of the acromion).Combining a latissimus dorsi tendon transfers with reverse total shoulder arthroplasty (R-TSA) helps to restore control of active external rotation. Dysfunction with external rotation can be determined clinically with external rotation lag sign, a positive Hornblower's sign, and radiographically with fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al.Gerber et al. found that R-TSA with combined lat dorsi transfer yielded minimal improvements in external rotation ROM (13 deg to 19 deg) compared to increases in shoulder ROM in flexion (94 deg to 137 deg) and abduction (87 deg to 145 deg), with this procedure.Boileau et al. examined 17 consecutive patients treated with reverse shoulder arthroplasty and latissimus dorsi and teres major transfer (L'Episcopo). They foundthat external rotation increased from -21 degrees to 13 degrees (+34 degrees ). They recommend transferring both the LD and TM, rather than the LD alone as it results in better active external rotation.Illustration A is a radiograph showing a right reverse total shoulder replacement. Illustration B shows a cadaveric image of the positioning of the latissimus dorsi tendon transfer prior to implantation of the reverse total shoulder components.Incorrect Answers

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals. REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427. Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

DISCUSSION: The patient has primary scapular-trapezius winging. This condition can be caused by blunt trauma to the relatively superficial spinal accessory nerve that is located in the floor of the posterior cervical triangle in the subcutaneous tissue. Other causes of injury include penetrating trauma, traction, or surgical injury. With trapezius winging, the shoulder appears depressed and laterally translated because of an unopposed serratus anterior. This contrasts with primary serratus anterior winging, which is caused by injury to the long thoracic nerve. In this condition, the scapula assumes a position of superior elevation and medial translation, and the inferior angle is rotated medially. The thoracodorsal nerve supplies the latissimus dorsi and is not involved in primary scapular winging. REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. Wright TA: Accessory spinal nerve injury. Clin Orthop 1975;108:15-18.

DISCUSSION: A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%. REFERENCES: Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130. Itoi E, Kuelchle DK, Newman SR, Morrey BF, An KN: Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546-550.

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?A. Open reduction internal fixation (ORIF) with parallel platesB. ORIF with orthogonal plates and iliac crest bone graftingC. Total elbow arthroplasty (TEA)D. Closed reduction and percutaneous pinningTEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower reoperation rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population. Correct answer : C

DISCUSSION: Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to 130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best. REFERENCES: Rittmeister M, Kerschbaumer M: Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10:17-22. Visotosky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40. Werner CM, Steinmann PA, Gilbart M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

DISCUSSION: The long thoracic nerve, which innervates the serratus anterior, is prone to injury because of its superficial location along the chest wall. The long thoracic nerve is derived from the roots of C5, C6, and C7. The spinal accessory nerve innervates the trapezius, and the thoracodorsal nerve innervates the latissimus dorsi. The posterior cord of the brachial plexus provides the axillary and the radial nerves. REFERENCES: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 259-340. Marmor L, Bechtal CO: Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle: A case report. J Bone Joint Surg Am 1983;45:156-160.

The patient is experiencing rotator cuff tear arthropathy. Given that this is the first medical treatment she has sought, a nonsurgical treatment plan of anti-inflammatory medication or a corticosteroid injection is warranted. Proceeding to the operating room without a trial of nonsurgical management is not indicated in this patient population. Surgical procedures may be necessary in the future if nonsurgical measures fail.

DISCUSSION: Treatment of shoulder instability with thermal devices has led to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.

The musculocutaneous nerve can be as close as 3 cm to the coracoid process; therefore, this relationship is important to keep in mind when performing surgery inthis area. Excessive traction on the musculocutaneous nerve could lead to a neurapraxia with resultant weakness of elbow flexion and forearm supinaton because of the loss of biceps function.

In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.

DISCUSSION: The musculocutaneous nerve travels through the conjoined tendon approximately 8 cm distal to the tip of the acromion. The musculocutaneous nerve innervates the biceps muscle and the brachialis muscle, both of which are responsible for elbow flexion. Shoulder flexion is facilitated by the anterior fibers of the deltoid muscle (axillary nerve) and the supraspinatus muscle (suprascapular nerve). The subscapularis muscle facilitates internal rotation of the shoulder (upper and lower subscapular nerves). Shoulder abduction is performed by the deltoid muscle (axillary nerve), and forearm pronation is facilitated by the pronator teres (median nerve).

DISCUSSION: Radiographs reveal malunion of a Monteggia fracture-dislocation. Dislocation of the posterior radial head is caused by the malunited ulnar fracture. The deformity includes shortening with an apex posterior angulation. In the acute setting, open reduction of the radial head rarely is necessary; however, in chronic dislocations, open reduction is required. Without ulnar osteotomy, recurrent radial head dislocation is likely.

The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’ssusceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.