Shoulder, Elbow, and Upper Extremity Sports

7


Shoulder, Elbow, and Upper Extremity Sports


Stacey Elisa Gallacher and Andrew Green


I. Anatomy


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



Acromial branch of thoracoacromial artery on medial aspect: can be a cause of bleeding during acromioplasty. Thoracoacromial artery is a branch of the axillary artery. Acromial branch emerges between pectoralis major and deltoid; enters vessel network over the acromion


• 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




• 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









Table 7.1 Glenohumeral Ligaments
























Structure


Arm Position When Ligament Is Active


Function


Coracohumeral ligament


Adducted arm


Limits inferior translation, external rotation


Superior glenohumeral ligament


Adducted arm


Limits inferior translation, external rotation


Middle glenohumeral ligament


45 degrees of abduction


Limits anterior translation


Inferior glenohumeral ligament


Abduction external rotation


Limits anterior and inferior translation


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





c. Distal humeral joint surface has 7 degrees’ valgus, 30 degrees’ anterior tilt, 5 degrees’ internal rotation


d. Maximal joint distention occurs at 70–80 degrees of flexion; effusion up to 20 cc of fluid results in flexed position of elbow


e. Distal anterior capsular attachment is located 6 mm distal to coronoid (tip of coronoid is intra-articular).


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



Lateral collateral ligament complex: composed of lateral ulnar collateral ligament; annular ligament, which attaches to radial neck; and the oblique cord


♦ Lateral ulnar collateral ligament (LUCL): lateral epicondyle to ulna crista supinatoris; deficiency results in posterolateral rotatory instability


♦ Most common elbow dislocation is posterolateral: all ligaments and capsule can be torn



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











3. Spaces/intervals (Fig. 7.23)



• Quadrangular space: teres minor (superior), teres major (inferior), long head of triceps (medial), humerus (lateral); contains axillary nerve and posterior circumflex humeral vessels


• Triangular space: teres minor (superior), teres major (inferior), long head of triceps (lateral); contains circumflex scapular vessels


• Posterior approach to the scapula is through the interval between infraspinatus and teres minor to avoid the triangular space


• 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



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.



Compression at suprascapular notch will weaken supraspinatus and infraspinatus; compression at spinoglenoid notch will only weaken infraspinatus.


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






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
























Components


Number


Location


1. Plexus roots (anterior rami of the spinal nerves from cord segments C5–T1)


5


Between scalenus anterior and scalenus medius (interscalene space)


2. The primary trunks: upper, middle, and lower


3


Lateral to the interscalene space and above the clavicle


3. The three anterior and three posterior divisions


6


Posterior to the clavicle


4. The lateral, medial, and posterior cords


3


In the axilla, posterior to pectoralis minor


Source: From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005:314. Reprinted with permission.


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



• 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



• 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






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


b. Structures at risk: axillary nerve, radial nerve, anterior circumflex humeral artery


• 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



• 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






Lateral: through anconeus


Posterior: 2–3 cm proximal to olecranon


Posterolateral: 2–3 cm proximal to olecranon, lateral to triceps tendon


Posteromedial: least safe; risks ulnar nerve; not recommended for use


b. Complications: most common nerve injury is transient ulnar nerve palsy


Some consider ulnar neuropathy and a history of prior ulnar nerve transposition as contraindications to arthroscopy; alternatively, can find and protect nerve


Posterior and posterolateral portals are safest for evaluation of posterior elbow


II. Shoulder Conditions


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
































































































Test Name


Technique


Associated Pathology


Neer impingement sign


Anterior superior shoulder pain with full passive forward elevation impingement


Impingement


Hawkins


Pain with passive forward flexion > 90 degrees in internal rotation


Impingement


Jobe


Pain with resisted elevation at 90 degrees with shoulder internally rotated and forearm pronated


Supraspinatus lesion


Drop-arm


Inability to maintain forward flexion in scapular plane


Large rotator cuff tear


Hornblower


Inability to actively externally rotate the arm in 90-degree abduction position


Massive posterior superior rotator cuff tear (supraspinatus, infraspinatus, possibly teres minor)


Liftoff


Inability to elevate hand off lower back or against resistance


Subscapularis injury


Belly press


Inability to keep hand on stomach against resistance


Subscapularis injury


Anterior apprehension


Pain/apprehension with abduction of 90 degrees and external rotation


Anterior instability


Relocation


Relief of pain/apprehension when applying posterior force during apprehension test


Anterior instability


Load and shift


Increased translation with anterior/posterior force on humeral head


Instability


Modified load and shift


Load and shift performed in supine position with elbow bent


Instability


Jerk


Clunk with posterior force on forward flexed/adducted arm and internally rotated (similar to Ortolani/Barlow),


Posterior glenohumeral instability


Sulcus


Increased acromiohumeral distance with inferior force on arm at side


Inferior laxity


Active compression (O’Brien)


Pain with resisted on arm in slight adduction/forward flexion 90 degrees/max pronation and relieved with supination/external rotation, pain located deep


SLAP lesion; AC pathology, rotator cuff pathology


Anterior slide


Pain with resistance with hand on hip


SLAP lesion


Crank


Pain with humeral loading and rotation in full abduction


SLAP lesion


Speed


Pain with resisted forward flexion in scapular plane


Biceps tendonitis


Yergason


Pain with resisted supination


Biceps tendinitis


Kim


Downward and posterior force on abducted shoulder while elevating shoulder


Posteroinferior labral lesion


Spurling


Pain/radicular symptoms with cervical spine lateral bending/extension/cervical loading


Cervical spine disease; use to differentiate shoulder pathology from cervical spine pathology


Wright


Loss of pulse/neurovascular symptoms with extension/abduction/external rotation of arm with neck rotated away


Thoracic outlet syndrome


Adson


Rotate head to ipsilateral side, extend neck, deep inspiration


Loss of radial pulse indicates thoracic outlet syndrome


Abbreviations: AC, acromioclavicular; SLAP, superior labral anteroposterior.


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


▪ Posterior superior: supraspinatus/infraspinatus


▪ Anterior: subscapularis


♦ HAGL (humeral avulsion of inferior glenohumeral ligament) lesion: can contribute to recurrent instability; associated with subscapularis tears


♦ Axillary nerve injury: most common nerve injury with anterior glenohumeral dislocation


Diagnostic evaluation


♦ Physical examination before and after closed reduction: assess rotator cuff strength; weakness suggests acute rotator cuff tear


♦ Neurovascular status


♦ Plain radiographs pre- and postreduction


♦ Rule out associated fractures of glenoid and proximal humerus.


♦ CT scan to evaluate bony pathology: glenoid fracture


♦ Magnetic resonance imaging (MRI) to evaluate for rotator cuff tear


Treatment


♦ Closed reduction


▪ Intra-articular local anesthetic, intravenous (IV) medications, conscious sedation


▪ Gentle manipulative reductions


♦ Immobilization: simple sling versus 30-degree external rotation immobilizer; external rotation may reduce recurrence rate (controversial)


♦ Recurrence rate inversely correlates with age at initial dislocation/injury


♦ Primary repair: reduces recurrence rate in younger patients


▪ Nonoperative treatment is first line for most patients


▪ Acute glenoid fracture: arthroscopic or open repair


b. Posterior


Mechanism of injury: posterior directed axial load; high-energy trauma, seizure, electric shock; seen in football linemen


Clinical presentation: arm locked in internal rotation in posterior dislocation


Associated pathology


♦ Posterior labral tear


▪ Reverse Hill-Sachs defect: chondral impaction injury in anteromedial humeral head; occurs with posterior dislocation


Diagnostic evaluation


♦ History of mechanism


♦ Physical examination: arm locked in internal rotation


♦ Imaging: posterior shoulder dislocations often missed


▪ Humeral head overlaps glenoid rim on true AP X-ray axial imaging; plain radiographs or CT scan


▪ Light bulb sign of humeral head seen with posterior dislocations; humerus internally rotated


▪ Rule out associated proximal humerus fracture


▪ CT to evaluate size of reverse Hill-Sachs lesion


Treatment


♦ Closed reduction: internal rotation and traction to disengage humeral head from glenoid


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


♦ 20–40% head defect: McLaughlin procedure; lesser tuberosity transfer


♦ > 40% head defect: humeral head allograft versus humeral head arthroplasty


▪ Inferior: luxatio erecta: arm in full abduction with inferior dislocation


• Recurrent/chronic glenohumeral instability


a. Pathogenesis


TUBS (traumatic unidirectional Bankart lesion): surgery often required


AMBRI (atraumatic multidirectional bilateral rehabilitation inferior) capsular shift


b. Evaluation


History of mechanism of injury


♦ Anterior: abduction external rotation


♦ Traumatic (recurrent posterior subluxation in football linemen) versus atraumatic


♦ Multidirectional: usually atraumatic; patients complain of pain more than instability


Physical examination


♦ Provocative maneuvers


▪ Anterior-load and shift, modified load and shift, anterior apprehension-relocation


▪ Multidirectional sulcus sign


▪ Posterior: jerk and Kim tests; load and shift


♦ Grades of instability on physical exam


▪ 0: normal, small amount of translation


▪ 1: humeral head to glenoid rim


▪ 2: humeral head over glenoid rim but spontaneously reduces


▪ 3: humeral head over glenoid rim and locks


♦ Sulcus sign: to test for multidirectional instability


▪ Grading: acromiohumeral distance


• 1: < 1 cm


• 2: 1–2 cm


• 3: > 2 cm


c. Imaging


Plain X-ray: three views of shoulder (true AP, axillary lateral, scapular Y); West Point view for glenoid bone defects/bony Bankart, Stryker notch view for Hill-Sachs defect


MRI: MR arthrogram increases specificity of MRI in detecting labral pathology


CT scan/CT arthrogram: better to evaluate bony pathology


Glenoid bone deficit best evaluated on sagittal MRI or CT


d. Pathological anatomy


Anterior


♦ Anterior capsulolabral lesions


♦ Glenoid rim fracture


♦ Hill-Sachs


Multidirectional


♦ Rarely labral tear; frequently hypoplastic labrum; increased capsular volume


♦ Generalized ligamentous laxity


Posterior


♦ Posterior labral tear in traumatic cases


♦ Kim lesion: avulsion of posteroinferior labrum that is incomplete and concealed; associated with posterior and multidirectional instability


e. Nonoperative management


Anterior: does not usually respond to rehab


Multidirectional instability: rehab is first-line treatment; extended course, closed kinetic chain exercises


Posterior: rehab more successful in atraumatic cases


f. Surgical management


Anterior


♦ Indications: recurrent instability (subluxation/dislocation), failure of conservative management


♦ Bankart: repair of labrum, gold standard: open versus arthroscopic


♦ Glenoid bone reconstruction/augmentation deficiency > 25%


▪ Latarjet: transfer coracoid to anterior inferior glenoid, secured with screws, risks are nonunion, articular injury, migration, nerve injury


▪ Glenoid bone graft


♦ Historical procedures


▪ Putti-Platt: subscapularis and anterior capsule overlapped to tighten; limits external rotation; late degenerative joint disease


▪ Magnuson-Stack: transfer subscapularis lateral to the biceps groove; limits external rotation; late degenerative joint disease


▪ Bristow: transfer tip of coracoid with attached tendons through subscapularis to anterior neck of scapula


♦ Outcome: arthroscopic capsulolabral repair has equivalent outcomes to open Bankart repair


♦ Complications


▪ Open repair: overtightening; subscapularis rupture


▪ Arthroscopic: overtightening; axillary nerve injury with inferior portal placement or inferior capsular suture


▪ Anchor displacement


Posterior


♦ Indications: recurrent instability (subluxation/dislocation), failure of conservative management


♦ Posterior Bankart: open or arthroscopic


▪ Posterior labroplasty: Kim lesion after failed conservative treatment


▪ Capsular shift if labrum intact of for associated multidirectional instability


▪ Rotator cuff interval closure reduces posterior instability


♦ Postoperative immobilization in gun-slinger position


♦ Complication: axillary nerve injury with posteroinferior labral repair (nerve passes within 1 mm of inferior capsule)


Multidirectional instability


♦ Indications: persistent symptoms, failure of conservative management


♦ Capsular shift: open versus arthroscopic; shift capsule superiorly; gold standard for multidirectional instability; risks overtightening


♦ Closure of rotator interval


♦ Thermal shrinkage no longer accepted treatment: associated with axillary nerve injury, chondrolysis, and capsular deficiency


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


• Pathogenesis


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


Jun 28, 2018 | Posted by in ORTHOPEDIC | Comments Off on Shoulder, Elbow, and Upper Extremity Sports
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