FRCS: Shoulder and elbow

Brachioradialis. Many muscle groups in the upper limb have dual innervation. Brachialis (musculocutaneous and radial), flexor digitorum profundus (anterior interosseus and ulna), lumbricals (recurrent median and ulna) and pectoralis major (lateral pectoral and medial pectoral) are examples.

Inferior glenohumeral ligament complex. The rotator cuff is a dynamic stabilizer and the capsulolabral tissues are considered static stabilizers. With the arm at 90
abduction, the anterior band of the inferior glenohumeral ligament complex is the primary static stabilizer to anterior translation.

Young age (<25 years old) at time of dislocation. The only consistent predictor of recurrence has been the age of the patient. In young patients (<25 years old), recurrence rates have ranged from 60% to 94%. Family history confers a 34% risk of recurrence, while dislocation in the contralateral shoulder is seen in 25% of recurrently unstable patients according to Hovelius et al. No difference in dominant and non-dominant extremities was noted.

Diabetes mellitus. Adhesive capsulitis affects an estimated 2–5% of the population. Several medical conditions have been associated with idiopathic adhesive capsulitis including diabetes and hypothyroidism. The reported incidence in diabetics is between 10% and 36%. Patients with insulin-dependent diabetes tend to have more severe limitation of movement and are more resistant to non-surgical treatment than non-insulin diabetics.

Medial scapular winging. The long thoracic nerve supplies serratus anterior, injury to which can result in medial translation of the scapular and the inferior angle rotated medially. Lateral scapular winging (lateral translation and the inferior angle rotated laterally) can occur as result of spinal accessory nerve palsy which supplies trapezius.

Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum. A Buford complex is a normal anatomical variant seen in 1.5% of individuals. A Buford complex consists of a cord-like MGHL and absent anterosuperior labrum complex. It should not be ‘repaired’. ‘Repair’ will result in decreased post-operative range of motion.

Risk of dislocation. As part of a deltopectoral approach, the subscapularis is taken down off the humerus. This may be done trans-tendon, directly off bone, or with a lesser tuberosity osteotomy. In the initial post-operative period passive external rotation is limited to a maximum 30
to allow healing and protect the repair.

Axillary. The most common nerve to be injured in a traumatic anterior shoulder dislocation is the axillary nerve. This is because of its close association with the glenohumeral joint and its course around the surgical neck of the humerus. Based on clinical and electromyography 39 (EMG) findings Visser et al. showed that the axillary nerve is injured in 42% of traumatic anterior dislocations.

Extensor carpi radialis brevis. The patient has lateral epicondylitis (tennis elbow), which usually involves a microtear of extensor carpi radialis brevis (ECRB). Histologically the lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration (angiofibroblastic dysplasia) of the origin of ECRB.

Anterior band of the medial ulnar collateral ligament. The anterior band provides the major contribution to valgus stability. The olecranon is an important stabilizer of the elbow in extension; at 25
flexion the olecranon is unlocked from its fossa and the ulnar collateral ligament becomes the most important stabilizer. The radial head is an important secondary stabilizer in flexion and extension. The posterior band of the medial ulnar collateral ligament is a secondary stabilizer at 30
of flexion. The transverse band plays no role in joint stability because it originates and inserts on the same bone.

Late cocking. The late cocking and early acceleration phase of the overhead throw causes the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the ulnar collateral ligament for stability. In deceleration, the elbow flexors are most active to prevent hyperextension.

Activity modification. Distal clavicular osteolysis is an uncommon cause of shoulder pain that can occur after acute injury or repetitive microtrauma. Initial treatment is non-surgical and includes activity modification and ACJ steroid injection. Arthroscopic resection of the distal clavicle should be considered in patients refractory to non-operative treatment.

Inferior glenohumeral. A humeral avulsion of the glenohumeral ligament (HAGL) lesion is a detachment of the inferior glenohumeral ligament (IGHL) off its humeral insertion. If missed, it can cause a failure of Bankart repair. The classic teaching is for repair via an open approach.

External rotation deficit. Healing of the tuberosities and their attached rotator cuff tendons is crucial in functional outcome after arthroplasty. Failure to properly position tuberosity fragments in the horizontal plane may result in insurmountable post-operative motion restriction.

Weakness in external rotation. Compression at the spinoglenoid notch will affect only the infraspinatus as the suprascapular nerve has already innervated the supraspinatus by this point. Compression at the suprascapular notch will affect both the supraspinatus and the infraspinatus. Prolonged impingement on the suprascapular nerve by a spinoglenoid cyst can result in atrophy of the infraspinatus muscles. This would show up as weakness in external rotation on examination. These cysts are associated with SLAP lesions and are formed 40 by a one-way valve effect, where synovial fluid can exit the joint into the cyst but not drain spontaneously.

Superior placement of the glenoid component. Superior positioning of the glenoid component as well as superior tilt of the component with respect to the scapula can lead to scapular notching, with a resultant poorer outcome. Inferior tilt and proper placement of the glenoid component protects against notching.

Anteroinferior labral tear. It has been shown in one study that 87% have an anterior glenoid labral tear (Bankart lesion), 79% had anterior capsular insufficiency, 68% had a Hill–Sachs lesion, 55% had glenohumeral ligament insufficiency, 14% had complete rotator cuff tears, 12% had posterior glenoid labral tears and 7% had SLAP tears.

Posterior interosseous nerve. The posterior interosseous nerve is vulnerable as it winds around the neck of the radius within the supinator muscle. Fully supinating the forearm displaces the nerve laterally and posteriorly (away from the surgical site) at the same time more fully exposing the insertion of supinator.

Decreased shoulder muscle strength and endurance. McKee found that patients who had non-operative treatment of displaced (> 2 cm) midshaft clavicle fractures had significant decrease in both strength and endurance of about 80% compared to the contralateral side. Range of motion (ROM) of the affected shoulder was unaffected.

Total elbow replacement. The Larsen classification of the rheumatoid elbow is based on plain radiographs and is graded I–V: Grade I – soft tissue swelling and osteoporosis. Grade II – mild narrowing of the joint space and some marginal erosion. Grade III – significant joint space narrowing. Grade IV – integrity of subchondral plates is breached by deep erosions. Grade V – total joint destruction

Rotator cuff repair. A shoulder dislocation in a patient >40 years commonly results in a rotator cuff tear. In a shoulder with an intact rotator cuff, the dye will remain in the glenohumeral joint. A rotator cuff tear allows the dye to leak into the subacromial space. The most appropriate treatment is a rotator cuff repair.

Radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair. A terrible triad of the elbow includes dislocation of the elbow with associated fractures of the radial head and the coronoid process. Ring et al. stressed that these injuries are prone to complications and advised against resection of the radial head due to instability, 41 and instead recommended a radial head replacement if too comminuted for open reduction and internal rotation (ORIF). Coronoid fractures compromise elbow stability as well and require open reduction and internal fixation as with the lateral collateral ligament.

Ligament avulsion off the humeral origin. The LUCL is most commonly injured at the proximal origin. McKee et al. noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in 1 and combined patterns in 3.

Suprascapular-axillary. Surgical fixation of a scapular neck fracture is performed via a posterior approach to the scapular/glenoid. The internervous plane is between the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve). The posterior branch of the axillary nerve has intimate association with the inferior aspects of the glenoid and shoulder joint capsule, and can be found in the interval between teres minor and teres major, which may place it at particular risk during a posterior approach to the shoulder.

Internal rotation (IR) 30º, Flexion 30º, Abduction 30º. Shoulder arthrodesis should be performed so that the arm rests comfortably at the side without scapular winging and so that the hand can be brought easily to the mouth and perineum. 42 1. All of the following statements regarding thoracolumbar trauma are true except? a. Instability of a vertebral fracture can be determined by loss of vertebral height >50%. b. There is no direct relationship between canal compromise and neurological deficit. c. Instability of injuries can be determined by further neurological deterioration under normal physiological load. d. Widening of the interpedicular distance on plain radiograph can indicate a burst fracture. e. In a thoracic burst fracture, a thoracolumbar orthosis is indicated if there is <50% loss of vertebral body height and >30% kyphosis. 2. All of the following statements regarding curve progression in adolescent idiopathic scoliosis are true except? a. With curves of 20–29
, 40% of patients who are Risser 0–1 are at risk of curve progression. b. With curves of 20–29
, 22% of patients who are Risser 2–4 progress. c. After skeletal maturity, a lumbar curve >35
can progress by 1–2
/year. d. A late curve progression in males is more common than in females. e. A rapid curve progression in females occurs before menarche and before Risser 1. 3. During an anterior instrumented fusion of the lumbar spine through a left-sided retroperitoneal approach, all of the following statements are correct except? a. The ureter is adherent to the posterior peritoneum and falls away from the psoas through the dissection. b. The sympathetic trunk, lying longitudinally along the lateral border of the psoas, is at risk during this procedure. c. The ilioinguinal nerve emerges from the lateral border of the psoas and travels to the quadratus lumborium. d. A cold and pale right foot is a recognized post-operative examination finding. e. The genitofemoral nerve lies on the anteromedial surface of the psoas. 4. All of the following statements regarding scoliosis in neurofibromatosis (NF) are true except? a. Non-dystrophic deformities are indistinguishable from idiopathic scoliosis. # Cambridge University Press 2012. 47