ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW 2
57) 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?
1. Ulnar nerve subluxation, extension splinting
2. Valgus extension overload, physical therapy incorporating flexor-pronator strengthening
3. Medial ulnar collateral ligament injury, ligament reconstruction using palmaris longus autograft
4. Posterolateral rotatory instability, LUCL reconstruction using palmaris longus autograft
5. Medial ulnar collateral ligament injury, PRP injection and physical therapy incorporating flexor-pronator strengthening
Corrent 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 over-resection 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 flexor-pronator 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 high level 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.
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58) 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 45- 110° of flexion/extension and 130° of total prono-supination. Which of these factors is a relative contraindication to arthroscopic release?
1. Age over 40 years
2. Male gender
3. Osteophyte formation in ulnohumeral joint
4. Prior ulnar nerve transposition
5. Heavy labor occupation
Corrent 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 prono supination, 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.
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59) 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?
1. Anterior inferior glenohumeral ligament
2. Coracohumeral ligament
3. Superior labrum
4. Infraspinatus tendon
5. Posterior labrum
Corrent 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 anti-inflammatory 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 full thickness subscapularis tear. The authors reported that of the 26 patients with biceps tendon subluxation preoperatively 9 were confirmed to have a full thickness 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 90- degree angle in patients without subluxation, which was statistically significant (p = 0.037). The authors concluded that there are steeper biceps tendon glenoid 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.
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60) 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?
1. Instability of dominant arm
2. Overhead throwing athlete
3. Age under 25 years
4. Labral tear involving the biceps attachment
5. An inverted pear-shaped glenoid on arthroscopy
Corrent 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 re emergence 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 (>20- 25%) 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 non dominant 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.
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61) 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?
1. Suprascapular nerve and Suprascapular notch
2. Axillary nerve and Quadrilateral space
3. Suprascapular nerve and Spinoglenoid notch
4. Upper subscapular nerve and Spinoglenoid notch
5. Radial nerve and Triangular interval
Corrent 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.
Aval et al. discusses neurovascular injuries to the athlete's shoulder and the sites of suprascapular 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.
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62) 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?
1. Anterior band of the inferior glenohumeral ligament
2. Middle glenohumeral ligament
3. Anterior labrum
4. Posterior band of the inferior glenohumeral ligament
5. Superior glenohumeral ligament
Corrent 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.
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63) 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?
1. Antero-inferior labral tear; arthroscopic labral repair
2. Posterior labral tear; arthroscopic labral repair
3. Posterior labral tear; arthroscopic thermal capsulorraphy
4. Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic labral debridement versus repair
5. Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic biceps tenodesis
Corrent 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.
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64) 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?
1. Posterior instability
2. Anterior instability
3. Suprascapular neuropraxia
4. Decreased internal rotation
5. Glenohumeral joint arthritis.
Corrent 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. Non operative 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.
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65) 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).
1. B and 2
2. C and 2
3. B and 3
4. D and 1
5. C and 3
Corrent 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 Flexor Pronator 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.
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66) 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 4. Surgical fixation with a cortical button offers the strongest repair 5. Synostosis is the most common complication following a single-incision surgical approach
Corrent 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 low demand 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 patient oriented outcome questionnaire following single-incision distal bicep repair using two suture anchors. This single surgeon population's mean Disabilities of the Arm, Shoulder, and Hand (DASH) score, 8.2, was 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 two incision surgical technique is an injury to the LABCN.
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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?
1. Lateral antebrachial neuritis
2. Loss of supination strength
3. Loss of supination endurance
4. Loss of flexion strength
5. Delayed return to activities
Corrent 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 non-operative 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.
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68) 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?
1. Distal humeral axial
2. West Point axillary
3. Zanca
4. Shoulder AP in external rotation
5. Swimmer's
Corrent 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.
Answer 5: A Swimmer's view is a radiograph of the cervical spine that is an additional lateral view obtained when a normal lateral view of the cervical spine does not have all 7 cervical vertebrae visible.
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69) 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?
1. Branches distal to the elbow, passing between two heads of pronator teres, running along volar aspect of the flexor digitorum profundus 2. Dives through the supinator, coursing around the radial neck within the deep compartment of the forearm
3. 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
4. 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
Corrent 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 single-incision 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, 5-8cm 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 7-9cm 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.
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70) 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?
1. Supraspinatus
2. Middle glenohumeral ligament
3. Subscapularis
4. Superior glenohumeral ligament
5. Anterior-inferior glenohumeral ligament
Corrent 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. Symptoms can follow a specific traumatic event that are exacerbated in the "provocative position" - 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.
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71) 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?
1. Increased time to healing with double-row repair compared to single-row repair
2. Decreased functional outcome scores with single-row repair compared to double-row repair
3. Decreased re-tear rate with double-row repair compared to single-row repair
4. Increased post-operative pain with double-row repair compared to single row repair
5. Less anatomic footprint restoration with a double-row repair compared to a single-row repair
Corrent 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 double-row 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 double-row 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 single-row 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 single-row RCR. Answer 5: A MORE anatomic restoration of the footprint is often cited with a double-row RCR compared to a single-row RCR.
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72) 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?
1. Chronic elbow instability
2. Chronic elbow pain
3. Decreased supination strength
4. A relative loss of elbow flexion compared to supination 5. Persistent lateral elbow pain with resisted wrist extension.
Corrent answer: 3
The patient has a left partial distal biceps tendon tear based on the MRI and clinical history. Non-operative 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 non operative 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 biceps deficient 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 T2- weighted 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 non operative 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.
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73) A 25-year-old bodybuilder presents to your clinic 3 days after injuring his left arm while weight lifting. He presents with pain and ecchymosis around his antecubital fossa. On examination, his hook test is abnormal. MRI studies are shown in Figures A through C. He inquiries about the risks of surgical repair. With respect to the most common sensory nerve and most common motor nerve that are injured during surgery, which of the following would be the expected post-operative neuro deficits?
1. Decreased sensation over lateral forearm and weakness in finger abduction 2. Decreased sensation over dorsal hand and weakness in wrist extension 3. Decreased sensation over lateral forearm and weakness in wrist extension 4. Decreased sensation over dorsal hand and weakness in thumb IP joint flexion
5. Decreased sensation over lateral forearm and weakness in thumb IP joint flexion
Corrent answer: 3
The patient in the vignette has sustained a complete distal biceps rupture and is inquiring about surgical repair. During repair, the most commonly injured sensory nerve is the lateral antebrachial cutaneous (LABC) and the most commonly injured motor nerve is the posterior interosseous nerve (PIN). Injury to the LABC would lead to decreased sensation over the lateral forearm and injury to the PIN would result in weakness in wrist extension.
There are many complications that can occur after surgical repair of a distal biceps tendon rupture. These include both relatively minor complications (20% risk) as well as major complications (4% risk). The most common minor complications are neuropraxia to the LABC (9%), heterotopic ossification (3- 4%), superficial radial nerve (SRN) palsy (2-3%), superficial infection (1%), and stiffness (1%). The most common major complications are PIN
neuropraxia (1-2%), re-rupture (1-2%), deep infection (1%) and radioulnar synostosis (1%). Regarding injury to the PIN, there had been data that suggested it was more common with a limited single incision approach but recent meta-analysis suggests the rate is similar to the dual incision approach. The most commonly discussed mechanisms of PIN injury are direct injury from radially based retractors and prolonged traction during the procedure. PIN entrapment by the cortical button may also occur.
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 biceps deficient 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 through C are T2-weighted axial and coronal MRI cuts that show a complete distal biceps tendon rupture off the radial tuberosity with proximal retraction of the tendon.
Incorrect Answers:
Answer 1: While an injury to the LABC is the most common sensory nerve complication, injury to the ulnar nerve (interosseous muscles) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair. Answer 2 and 4: Injury to the SRN is the 2nd most common sensory nerve complication after an injury to the LABC.
Answer 5: While an injury to the LABC is the most common sensory nerve complication, injury to the AIN nerve (FPL) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair.
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74) A 43-year-old male laborer presents to your office for evaluation of right shoulder pain. He describes the location of the pain as "patch like" over the lateral shoulder without pain anteriorly. He denies any previous surgeries on this shoulder, but has been treated with physical therapy, steroid injections, rest, and anti-inflammatories for the last year. On exam he has full passive range of motion with significant weakness with external rotation and an intact belly press test. MRI demonstrates a full thickness supraspinatus and infraspinatus tears with retraction medial to the glenoid. After thorough discussion the patient elects to proceed with tendon transfer, which of the following transfers would most benefit this patient?
1. Pectoralis major
2. Pectoralis minor
3. Latissimus dorsi
4. Conjoined
5. Long head of the biceps
Corrent answer: 3
This patient has a massive retracted rotator cuff tear, and elects to proceed with tendon transfer. The best treatment option for a patient with posterosuperior cuff deficiency is a latissmus dorsi transfer.
Two tendon transfers are commonly used for massive and irreparable rotator cuff tears, especially in younger patients - pectoralis major and latissimus dorsi. The pectoralis major is best transferred for chronic irreparable subscapularis tears, in which it's transferred under the conjoined tendon to replicate the native force vector of the subscapularis. Latissimus dorsi tendon transfer, however, is utilized in patients with massive irreparable supraspinatus and infraspinatus tears, in which it is transferred to the supraspinatus, subscapularis and greater tuberosity. Those patients with deltoid or subscapularis dysfunction, nonsynergistic muscle action after transfer or significant fatty infiltration of the posterosuperior rotator cuff have worse clinical outcomes following latissimus dorsi transfer. Alternatively, the lower trapezius, often augmented with an achilles allograft, may also be transferred for the treatment of irreparable posterosuperior rotator cuff tears.
Elhassan et al review the management of failed rotator cuff repairs in young patients. They report that many factors should be evaluated when determining the best treatment for patients with failed rotator cuff repairs including patient age, tendon quality, tear characteristics and chronicity, and tobacco use. They conclude that for irreparable posterosuperior tears, latissimus dorsi transfer results in improved Shoulder Subjective Value (SSV) scores, constant assessment scores, range of motion and pain. They also highlight that patients must have an intact subscapularis for this treatment to be successful.
Omid et al review the various tendon transfers used for irreparable rotator cuff tears. They report that while surgical indications are not clearly defined, the ideal candidate is a young active patient with an irreparable rotator cuff that lacks glenohumeral arthritis. They conclude that patients with posterosuperior rotator cuff deficiency may be treated with trapezius or latissimus dorsi tendon transfers with the ladder having a more predictable outcome.
Incorrect Answers:
Answer 1: Pectoralis major transfers are utilized in patients with irreparable subscapularis tears.
Answer 2: Transferring the pectoralis minor would not recreate the force vector or function of the posterosuperior rotator cuff that is deficient in this
patient.
Answer 4: Conjoined tendon transfer is utilized for shoulder instability, not rotator cuff tears.
Answer 5: Tenodesis of the long head of the biceps to the humeral shaft may be performed for proximal biceps tendonitis, but has no function in transfer for rotator cuff deficiency.
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75) A 22-year-old male collegiate swimmer has a 4-month history of left shoulder pain without inciting trauma. On examination, he demonstrates 4/5 motor strength in forward elevation and abduction. Figure A shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve seen in Figure B?
1. A
2. B
3. C
4. D
5. E
Corrent answer: 1
This patient has medial scapular winging secondary to weakness of the serratus anterior. This muscle is innervated by the long thoracic nerve.
The long thoracic nerve consists of ventral rami of C5, C6, and C7. Non iatrogenic injury to the long thoracic nerve most often occurs secondary to repetitive stretching or compression, as seen in swimmers. The weakness of the serratus anterior leads to the elevation of the medial scapula with excessive medializing scapular retraction (rhomboid major and minor) and elevation (trapezius). Observation of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstay of treatment.
Nawa reported on a rare case of winging of the scapula that occurred during synchronized swimming practice in a 14-year-old female. He found that after 1 year of therapy, shoulder girdle pain and paresthesia had resolved but scapular winging remained. He concluded that damage to the nerve proximal to the branch arising from the upper nerve trunk may result in persistent scapular winging which is unresponsive to therapy.
Gooding et al. reviewed the causes of scapular winging. They report that lesions of the long thoracic nerve remain the most common etiological factor. They conclude that the majority of long thoracic nerve injuries resolve with conservative management.
Figure A is the clinical image of medial scapular winging suggestive of a long thoracic nerve injury. Figure B is an illustration of the brachial plexus. Illustration A is the illustration of the brachial plexus with labeled nerves.
Incorrect Answers:
Answer 2: This is the medial pectoral nerve
Answer 3: This is the thoracodorsal nerve
Answer 4: This is the medial brachial cutaneous nerve
Answer 5: This is the medial antebrachial cutaneous nerve
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