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1. Bony and articular anatomy (Fig. 7.1)

• Clavicle

a. First bone to ossify (at 5 weeks’ gestation), last to fuse (medial clavicular physis at 25 years of age)

b. Most common musculoskeletal injury at birth is clavicle fracture

• Scapula (Fig. 7.2)

a. Glenoid orientation: 7 degrees’ retroversion to 10 degrees’ anteversion

b. Suprascapular notch: superior transverse scapular ligament (artery above, nerve below)

c. Spinoglenoid notch: inferior transverse scapular ligament (artery and nerve both below)

d. Coracoacromial ligament: forms anterior superior aspect of coracoacromial arch, restrains superoanterior displacement of humeral head; preserve when massive irreparable rotator cuff tear present

• Humerus (Fig. 7.3)

a. Humeral head retroverted 20 degrees; average diameter 44–46 mm and is smaller in women than in men; head is mean 130-degree angle to shaft

b. Anatomic neck: location of capsular attachment

c. Surgical neck: juncture of shaft with tuberosities

d. Greater tuberosity: attachment for rotator cuff muscles and tendons; supraspinatus, infraspinatus, teres minor

e. Lesser tuberosity: attachment of subscapularis

f. Bicipital groove: transverse humeral ligament restrains biceps long head tendon

g. Posterior spiral groove: radial nerve, 13 cm superior to trochlea

Fig. 7.1 Shoulder and elbow bony anatomy. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.2 The right scapula. (a) Lateral view. (b) Anterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

• Glenohumeral joint: ball and socket; large degree of motion; most frequently dislocated major joint (Figs. 7.4 and 7.5)

a. Range of motion: 40 degrees of extension to 150–170 degrees of forward elevation; 20–40 degrees of adduction to 160–180 degrees of abduction

b. Position of arthrodesis: 20–30 degrees of abduction, 20–30 degrees of forward flexion, 20–30 degrees of internal rotation

c. Static restraints: labrum, capsule, ligaments, negative intra-articular joint pressure (Figs. 7.6, 7.7, 7.8, 7.9)

◦ Static restraints (Table 7.1)

◦ Anterior band of inferior glenohumeral ligament restricts anterior translation of arm in 90 degrees of abduction and maximal external rotation.

◦ Middle glenohumeral ligament: limits anterior translation

◦ Superior glenohumeral ligament: limits inferior translation

◦ Coracohumeral ligament: primary restraint to inferior humeral translation; also important for posterior stability

◦ Coracoacromial ligament: restrains anterior and inferior translation; resection increases glenohumeral joint translation

d. Dynamic restraints: rotator cuff is main dynamic restraint; serves to compress humeral head against glenoid and contributes to concavity compression

◦ Concavity compression is most important stabilizer in midrange of motion.

e. Rotator cable: thickening of supraspinatus and infraspinatus tendons; borders the avascular zone of rotator cuff near insertion; decreases stress at avascular zone

Fig. 7.3 The right humerus. (a) Anterior view. (b) Posterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.4 Bony anatomy of glenohumeral joint. (a) Anterior view. (b) Posterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.5 Normal shoulder range of motion. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.6 Ligaments and capsule of the glenohumeral joint. (a) Anterior view. (b) Posterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.7 Subacromial bursa and glenoid cavity of the right shoulder joint. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.8 Transverse section through the right shoulder joint. Superior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.9 Coronal section through the right shoulder joint. Anterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Table 7.1 Glenohumeral Ligaments

f. Buford complex (Fig. 7.10): anatomic variant not to be confused with an anterior labral tear; cord-like middle glenohumeral ligament, absent anterosuperior labral complex; normal variant if repaired results in lack of external rotation

• Sternoclavicular joint: medial clavicle articulates with manubrium

a. 30 degrees of upward elevation with arm elevation from 30 to 90 degrees

b. Posterior capsule/ligaments most important stabilizers

c. Serendipity view to evaluate radiographically (40-degree cephalic tilt) versus computed tomography (CT) scan

• Acromioclavicular joint (Fig. 7.11)

a. Acromioclavicular ligaments: prevent anteroposterior (AP) displacement

b. Coracoclavicular ligaments: trapezoid is anterolateral, conoid posteromedial and strongest; prevent superior displacement of clavicle

c. Zanca view for radiographic evaluation (10-degree cephalic tilt, one-half voltage)

• Scapulothoracic articulation (Fig. 7.12)

a. Angled 30 degrees anterior and 3 degrees superior tilt

b. Ratio of scapulothoracic to glenohumeral joint motion during abduction = 1:2

• Elbow (Fig. 7.13)

a. Range of motion: 0 degrees’ extension to 145 degrees’ flexion; 70 degrees’ pronation; 85 degrees’ supination; function range of motion is 30–130 degrees of flexion-extension and 50/50 pronation/supination

b. Position of arthrodesis: unilateral in 90 degrees of flexion and up to 7 degrees of valgus; if bilateral, fuse one in 110 degrees of flexion for feeding and the other at 65 degrees of flexion for perineal hygiene

Fig. 7.10 Buford complex. IGHL, inferior glenohumeral ligament; MGHL, middle glenohumeral ligament.

Fig. 7.11 The acromioclavicular joint and its ligaments. Anterior view. (Modified from Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.12 Scapulothoracic articulation. Anterosuperior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

f. Ligaments (Fig. 7.14):

◦ Medial collateral ligament: anterior, posterior, transverse bundles

♦ Anterior bundle most important stabilizer against valgus stress; originates on medical epicondyle and attaches 18 mm distal to tip of coronoid on sublime tubercle (anteromedial facet of coronoid); primary stabilizer of elbow against valgus stress from 20–120 degrees of motion; Tommy John reconstruction

♦ Posterior bundle: tight from 60–120 degrees, elongates with flexion and has larger change in tension during motion than anterior bundle

Fig. 7.13 Elbow joint bony and articular anatomy. (a) Anterior view. (b) Posterior view. (c) Lateral view. (d) Medial view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.14 The capsule and ligaments of the right elbow joint in 90-degree flexion. (a) Posterior view. (b) Medial view. (c) Lateral view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

2. Muscles (Figs. 7.15, 7.16, 7.17, 7.18, 7.19, 7.20, 7.21, 7.22)

• Muscles including origin, insertion, innervations, action (Table 7.2)

• Long head of biceps tendon has posterior or posterior dominant attachment to superior glenoid labrum in 70% of patients; collagen fibers of long head of biceps tendon and superior glenoid labrum overlap

• Rotator cuff: supraspinatus, infraspinatus, and teres minor attaching to greater tuberosity; subscapularis attaching to lesser tuberosity; average supraspinatus insertion (footprint) from medial to lateral is 14–16 mm

Fig. 7.15 Coronal and sagittal sections through ulnohumeral joint. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.16 Posterior muscles of the shoulder and arm. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.17 Posterior muscles of the shoulder and arm. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.18 Origin and insertion of muscles of shoulder and arm. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.19 Muscles of the right shoulder and right arm from the anterior view. The origins and insertions of the muscles are indicated by color shading: origin (red); insertion (blue). (a) After removal of the thoracic skeleton. Latissimus dorsi and serratus anterior have been removed to their insertions. (b) Latissimus dorsi and serratus anterior have been completely removed. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.20 Muscles of the right shoulder and right arm from the anterior view. All the muscles have been removed. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.21 Surgical approaches to humerus. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.22“Windowed” dissection of the right arm. Anterior (ventral) view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

3. Spaces/intervals (Fig. 7.23)

• Triangular interval: teres major (superior), long head of triceps (medial), lateral head of triceps/humerus (lateral); contains radial nerve and profunda brachii artery

• Rotator interval: coracoid base (medial), supraspinatus (superior), subscapularis (inferior); contains coracohumeral ligament, superior glenohumeral ligament, biceps tendon, glenohumeral capsule

Fig. 7.23 Posterior shoulder spaces and intervals. (Modified from Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

4. Nerves (also see Chapter 9) (Figs. 7.24, 7.25, 7.26, 7.27, Table 7.3)

• Understanding anatomic relationships helps determine level of injury to brachial plexus; exits neck with subclavian artery between anterior and middle scalene muscles (interscalene groove)

• Organized into roots (C5-T1), trunks, divisions, cords, and nerves; upper two roots (C5–C6) join to form the upper trunk at Erb’s point, located 2–3 cm above the clavicle, just behind posterior edge of the sternocleidomastoid; divisions split above the clavicle; cords are named according to their relationship to the axillary artery

• Supraclavicular branches: dorsal scapular, long thoracic, suprascapular, nerve to subclavius

• Specific anatomic consideration (Fig. 7.28)

a. Musculocutaneous: pierces coracobrachialis 2–8 cm (mean 5 cm) distal to coracoid

b. Axillary: travels underneath deltoid 5 cm inferior to lateral edge of acromion

c. Suprascapular nerve (passes through suprascapular notch): motor branches to supraspinatus located 3 cm from origin of long head of biceps, and motor branches to infraspinatus located 2 cm from superior glenoid rim

◦ Infraspinatus branch passes in spinoglenoid notch and can be compressed by spinoglenoid notch cyst from posterior superior labral tear.

d. Radial: in spiral groove 13 cm proximal to trochlea, pierces lateral intermuscular septum 7–10 cm proximal to trochlea

e. Ulnar: medial to brachial artery in the arm

f. Median: crosses brachial artery lateral to medial

Fig. 7.24 Linear diagram of brachial plexus and branches.

Fig. 7.25 The brachial plexus. (a) Names and sequence of the various elements of the brachial plexus. (b) Relationship of the lateral, medial, and posterior cords of the brachial plexus to the axillary artery. (c) Subdivision of the brachial plexus cords into their main branches. (Modified from Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.26 Cutaneous innervation of the upper extremity. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.27 (a) Segmental, radicular cutaneous innervation pattern (dermatomes) in the right upper limb. Posterior view. (b) Peripheral sensory cutaneous innervation pattern in the right upper limb. Posterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Table 7.3 Number and Location of the Main Components of the Brachial Plexus

5. Vessels (Figs. 7.29 and 7.30)

• Subclavian artery: left subclavian arises from aorta, right from brachiocephalic trunk

• Axillary artery: three parts based on relationship with pectoralis minor

a. First part: medial to pectoralis minor; one branch (supreme thoracic)

b. Second part: under pectoralis minor; two branches (thoracoacromial, lateral thoracic)

c. Third part: lateral to pectoralis minor; three branches (subscapular, anterior humeral circumflex, posterior humeral circumflex)

◦ Posterior humeral circumflex: dominant supply to humeral head ~ 60%), supplies posterior aspect of greater tuberosity, small area of posteroinferior humeral head

◦ Anterior humeral circumflex artery supplies humeral head via anterolateral ascending branch

6. Surgical approaches to shoulder

• Anterior deltopectoral (Henry approach) (Fig. 7.31)

a. Interval: deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves)

◦ Find cephalic vein and protect

b. Structures at risk: axillary nerve (medial inferior to subscapularis muscle and lateral under deltoid, musculocutaneous nerve with dissection medial to or excessive medial retraction on coracobrachialis)

c. Extensile approach: shoulder arthroplasty, anterior instability repair, open reduction and internal fixation (ORIF) proximal humerus

• Lateral deltoid splitting

a. Interval: deltoid splitting; between anterior and middle deltoid versus middle deltoid

b. Structures at risk: axillary nerve (avoid deltoid split more than 5 cm inferior to lateral edge of acromion)

c. Open rotator cuff repair; ORIF greater tuberosity; extended approach for ORIF proximal humerus

Fig. 7.28 Nerves that are closely related to the humerus. Right humerus, anterior view (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

• Posterior (Fig. 7.32)

a. Interval: infraspinatus (suprascapular nerve) and teres minor (axillary nerve); also may split infraspinatus transversely rather than true internervous interval

b. Structures at risk: quadrangular space structures (axillary nerve and posterior circumflex vessels) with dissection inferior to teres minor, suprascapular nerve with excess medial retraction

c. Posterior instability repair, ORIF posterior glenoid/scapula

Fig. 7.29 Origin and branches of axillary artery. Right shoulder, anterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

• Arthroscopy (Fig. 7.33)

a. Posterior portal: primary viewing portal into glenohumeral joint; 1 cm medial and 2 cm inferior to posterolateral border of acromion; axillary and suprascapular nerves potentially at risk

b. Anterior superior portal: risks injury to musculocutaneous nerve

c. Anterior inferior portal: do not go below subscapularis (risks axillary nerve and musculocutaneous nerve) or medial to conjoined tendon

d. Lateral portal: 1–3 cm distal to lateral edge of acromion

e. Inferior portals (anterior and posterior): risk injury to axillary nerve

f. Supraspinatus (Neviaser portal): risks suprascapular nerve if portal placement is too medial

7. Surgical approaches to humerus

• Proximal anterior/anterolateral

Fig. 7.30 Arterial supply to the scapular region. Right shoulder, posterior view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.31 Surgical approach to shoulder. Dashed line, deltopectoral; line of circles, deltoid split. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.32 Posterior approach to shoulder. Solid line, skin incision; line of circles, internervous plane. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.33 Arthroscopic portals of the shoulder.

• Distal anterolateral (Fig. 7.34)

a. Interval: brachialis (radial and musculocutaneous nerves) and biceps (musculocutaneous nerve), or brachialis splitting (radial and musculocutaneous nerves); retract biceps medially

b. Structure at risk: radial nerve

• Posterolateral

a. Interval: triceps and brachioradialis (both radial nerve)

b. Structure at risk: radial nerve at proximal extent

• Posterior

a. Interval: lateral and long heads of triceps (radial nerve)

b. Structures at risk: radial nerve and profunda brachii artery; can split triceps 15–16 cm proximal to lateral epicondyle (radial nerve crosses humerus at this point)

8. Surgical approaches to elbow

• Posterior (Fig. 7.35)

a. Approaches

◦ Detach triceps: detach from olecranon with a thin wafer of bone

◦ Olecranon osteotomy: apex–distal chevron osteotomy; reflect triceps tendon with osteotomized portion of olecranon

◦ Triceps reflecting (Bryan-Morrey approach): triceps and anconeus elevated as one flap from medial to lateral

◦ TRAP (triceps reflecting anconeus pedicle): extensile exposure that maintains triceps and anconeus continuity to protect neurovascular pedicle to anconeus; medial interval is along triceps proximally and between anconeus and flexor carpi ulnaris distally; lateral interval is between anconeus and extensor carpi ulnaris

◦ Triceps on: attachment of triceps to proximal ulna is maintained

◦ Triceps split: midline longitudinal incision through triceps fascia and tendon, split muscle and tendon longitudinally

b. Structures at risk: ulnar nerve, radial nerve

Fig. 7.34 Surgical approaches to humerus. Solid line, distal anterolateral; hash line, posterolateral; line of circles, posterior. (Modified from Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

• Medial (Fig. 7.36)

a. Interval: brachialis (radial and musculocutaneous nerves) and triceps (radial nerve) proximally, brachialis and pronator teres (median nerve) distally

b. Structures at risk: ulnar and medial antebrachial cutaneous nerves

• Medial splitting: split common flexor muscle bundle; used for ulnar collateral ligament reconstruction, coronoid fractures

• Lateral extensor splitting: between extensor digitorum communis and extensor carpi radialis brevis and longus superficially; deep dissection splits annular ligament anterior to lateral ulnar collateral ligament; approaches to capitellar, lateral condyle, and radial head fractures, as well as contracture releases

• Anterolateral (Henry approach)

a. Interval: brachialis splitting proximally, pronator teres (median nerve) and brachioradialis (radial nerve) distally

b. Structures at risk: lateral antebrachial cutaneous nerve, brachial artery, median nerve; may need to ligate radial recurrent artery

• Posterolateral (Kocher approach) (Fig. 7.37)

a. Interval: anconeus (radial) and extensor carpi ulnaris [posterior interosseous nerve (PIN)]

b. Structures at risk: PIN (pronate arm to move nerve anterior and radial to protect it)

• Arthroscopy

a. Portals (Fig. 7.38)

◦ Anterolateral: 1 cm distal and 1 cm anterior to lateral epicondyle; placed after joint distention; risks radial and lateral antebrachial cutaneous nerves

◦ Proximal anteromedial: 2 cm distal and 2 cm anterior to epicondyle; risks medial antebrachial cutaneous and median nerves

Fig. 7.35 Posterior approach to elbow. Solid line, skin incision. (Modified from Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.36 Surgical approach to elbow. Solid line, medial; dotted line, anterolateral. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.37 Posterolateral approach to elbow. Thick line, interval. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.)

Fig. 7.38 Arthroscopic portals of the elbow.

◦ Lateral: through anconeus

1. Physical examination (Table 7.4)

2. Radiographic views of shoulder

• True AP (Grashey view): X-ray beam perpendicular to scapula; parallel to glenohumeral joint

• 45-degree abduction true AP: glenohumeral joint space

• Axillary lateral: arm abducted 70–90 degrees, beam directed at axilla; dislocation/subluxation, arthritis of glenohumeral joint

• Outlet (y-view): patient stands with affected side rotated toward cassette; acromial morphology

• Zanca: 10-degree cephalic tilt; acromioclavicular (AC) joint

• Serendipity: 10-degree cephalic tilt; sternoclavicular (SC) joint

• West Point: X-ray beam aimed 25 degrees medially from midline (toward axilla) and 25 degrees anterior of a prone patient; evaluate Bankart lesions

• Stryker notch: X-ray beam 10 degrees cephalad of supine patient with shoulder forward elevated 120 degrees; evaluate Hill-Sachs defects

3. Shoulder instability: glenohumeral joint most commonly dislocated major joint in body

• Traumatic glenohumeral dislocation

a. Anterior

◦ Mechanism: shoulder dislocation with arm abducted and externally rotated; direct blow to posterior shoulder

◦ Clinical presentation: pain, limited internal rotation with anterior dislocation

◦ Associated pathology

♦ Bankart lesion: anterior labral tear; detachment of anteroinferior labrum and middle and inferior glenohumeral ligaments; most common finding during surgery for traumatic anterior shoulder dislocation in patients of ages < 40 years

▪ Bony Bankart: anteroinferior glenoid rim fracture very common in younger patients

▪ Labral injury variations

♦ Perthes lesion: nondisplaced labral tear with intact medial scapular periosteum

♦ ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion

♦ Glenolabral articular disruption: labral tear extending into articular cartilage

♦ Hill-Sachs defect: chondral impaction injury in posterosuperior humeral head, occurs with anterior dislocation

Table 7.4 Shoulder Exam Tests

♦ Rotator cuff tear: more common in patients of ages > 40 years

♦ < 20% head defect (reverse Hill-Sachs defect): reduce and treat conservatively; initial immobilization in external rotation

♦ Generalized ligamentous laxity

4. Biceps tendon and superior labral anteroposterior (SLAP) pathology

a. Classification of SLAP tears (Fig. 7.39)

◦ Type I: biceps fraying, intact labral anchor

◦ Type II: most common, detachment of biceps anchor

◦ Type III: bucket-handle tear of superior labrum, biceps intact

◦ Type IV: bucket-handle superior labral tear extends into biceps

◦ Type V: anterior labral tear plus SLAP

◦ Type VI: superior flap tear

◦ Type VII: capsular injury plus SLAP

b. Biceps tendinopathy: sometimes but not always associated with rotator cuff disease; can be isolated

c. Biceps subluxation: associated with tears subscapularis tendon, coracohumeral and transverse humeral ligaments (hidden lesion)

• Clinical Presentation

a. SLAP: pain, biceps tenderness; positive O’Brien test and anterior slide, crank, and dynamic labral shear tests; cause of symptoms in younger patients, overhead athletes, axial load injuries

b. Biceps tendinitis: pain, biceps tenderness, positive Speed and Yergason tests

c. Biceps subluxation: palpable click with arm abduction/external rotation

• Diagnostic workup

a. MRI arthrogram: high sensitivity and specificity for labral pathology

• Treatment: for symptomatic SLAP and/or biceps pathology

a. SLAP

◦ Patients of ages < 40: debridement for types I, III, VI; repair types II, V, VII; biceps tenodesis versus repair type IV

◦ Patients of ages > 40: biceps tenodesis or tenotomy

b. Biceps tendinitis/subluxation

◦ Conservative: initial treatment; strengthening, corticosteroid injection

◦ Surgical: refractory cases treated with tenotomy or tenodesis, with or without subscapularis repair in cases of subluxation

• Rehabilitation

a. SLAP repair: passive motion acutely postoperative to prevent stiffness, active motion in scapular plane at 4–8 weeks, strengthening last

• Outcomes

a. Biceps tenodesis with interference screw: strongest initial fixation, better prevents distal migration of tendon

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