ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW3

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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%).

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.

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.

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.

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.

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.

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.

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

76) A 20-year-old competitive weightlifter presents with complaints of right shoulder pain for 6 months. He undergoes a diagnostic acromioclavicular joint injection which provides significant pain relief. He has failed conservative management and elects to proceed with arthroscopic distal clavicle excision. Three months following surgery, he continues to complain of a painful popping sensation. It is determined that damage to the structure highlighted in red occured intraoperatively. Which type of clavicular instability is MOST likely to be observed in this patient?

1. Anterior

2. Inferior

3. Posterior

4. Rotational

5. Superior

Corrent answer: 3

This patient sustained injury to the posterior and superior acromioclavicular (AC) ligaments resulting in posterior AC joint instability.

The AC joint is a diarthrodial joint that articulates the scapula with the clavicle. It contains a fibrocartilaginous intraarticular disc analogous to the meniscus of the knee and has a small articular surface area with relatively high axial and rotational loads. The ligaments of the AC joint play a pivotal role in its stability. Unlike the coracoclavicular ligaments (conoid and trapezoid) which are important in superior stability of the distal clavicle, the AC ligaments are most important with anterior-posterior stability. Injury to the AC ligaments most commonly occurs secondary to aggressive surgical distal clavicle resection ( >1-1.5cm). Injury to the posterior and superior AC ligaments result in primary posterior instability of the distal clavicle. Conversely, injury to the anterior and superior AC ligaments results in anterior instability of the clavicle.

Strauss et al. review the causes of failure following distal clavicle excision (DCE) including over-resection leading to joint instability. They report that persistent symptoms and disability after DCE requires the formulation of a

treatment plan, which may include conservative management, revision surgery, or ligament reconstruction. They conclude that proper surgical technique and appropriate rehabilitation during the index procedure can minimize the likelihood of poor outcome.

Nuber et al. reviewed AC joint injuries. They report on the usefulness of an injection of bupivicaine into the AC joint to evaluate the source of pain about the symptomatic shoulder. They also note that the amount of bone resection necessary with arthroscopic technique is less than with the open procedure due to the ability to preserve the stabilizing properties of the superior AC ligaments. They conclude that resection of 4 mm to 8 mm of bone is all that may be required to give uniformly good results with arthroscopic DCE.

Figure A is an axial view depicting the AC joint ligaments

Incorrect Answers:

Answer 1: Injury to the anterior and superior AC ligaments would result in anterior instability of the distal clavicle

Answer 2: The coracoclavicular ligaments prevent superior displacement of the distal clavicle. Inferior instability is a rarely observed type of distal clavicle

instability

Answer 4: The AC joint experiences rotational forces at baseline. Rotational instability is rarely observed

Answer 5: Superior instability may be observed with injury to the coracoclavicular (conoid and trapezoid) ligaments

77) A 60-year-old patient fell down a flight of stairs and injured their right arm. Since the fall they are unable to move their extremity due to pain. Prior to the fall, the patient denied any pain in the shoulder or upper arm. Currently, the patient is neurovascularly intact. Figures A and B are the radiographs at the time of presentation. What is the best treatment option for this patient?

1. Revision rTSA with cemented long-stem prosthesis

2. Revision rTSA with cementless long-stem prosthesis

3. ORIF with hybrid locking plate and cerclage cables

4. ORIF with lag screw fixation and neutralization plating

5. Nonoperative treatment

Corrent answer: 3

The patient has sustained a Wright and Cofield type B periprosthetic humeral shaft fracture with a stable prosthesis. The best treatment option for this would involve ORIF with hybrid locking plate and cable construct.

Periprosthetic humeral shaft fractures are a relatively rare complication occurring in approximately 0.6-3% of patients that have undergone shoulder replacement procedures. These fractures pose treatment challenges as the prosthesis disrupts endosteal blood supply, causing higher nonunion rates. Fractures can be classified using the Wright and Cofield system: Type A fractures are proximal to the stem tip and are treated with ORIF; Type B fractures are at the level of the stem tip and are treated with ORIF; and Type C fractures are distal to the stem tip and can be initially treated nonoperatively.

Kurowicki et al. performed a case series of 7 patients with Wright and Cofield Type B periprosthetic humeral shaft fractures treated with open reduction internal fixation without implant revision. Internal fixation consisted of a lateral hybrid plate with skiving locking screws and cerclage cables proximally and cortical as well as locking screws distally. All patients treated achieved radiographic union.

Campbell et al. performed a retrospective analysis on 21 periprosthetic humeral shaft fractures that occurred either intraoperatively or postoperatively, 16 of which were intraoperative fractures. The authors found that fractures with a stable intramedullary fixation and combined supplementary fixation had had superior results with regards to union, complications, and rehabilitation compared to loose stem fixation with or without supplementary fixation.

Steinmann et al. reviewed the treatment of periprosthetic humeral shaft fractures. For intraoperative fractures, the authors recommended placement of a long stem prosthesis that bypasses the fracture site by at least 2 cortical diameters. For postoperative type A and B fractures, treatment depends on whether the stem is loose or well fixed. Loose prostheses necessitate revision long stem component with supplementary fixation, whereas well-fixed stems require hybrid plate fixation. Type C fractures can be treated non-operatively,

but in the presence of nonunion may require plate fixation with or without allograft struts.

Andersen et al. 2013 performed a retrospective cohort study on 36 patients with periprosthetic humeral shaft fractures, of which 17 were treated with ORIF and 19 underwent revision arthroplasty. Revision arthroplasty was performed when a prosthesis was determined to be loose at the time of surgical treatment. All patients treated with ORIF alone and 18/19 patients with revision arthroplasty achieved radiographic union. Fourteen patients experienced complications, seven were in each group.

Figures A and B are AP and lateral radiographs demonstrating a Wright and Cofield type B periprosthetic humeral shaft fracture. Illustration A depicts the Wright and Cofield classification system.

Incorrect Answers:

Answer 1: In the setting of a loose prosthesis, revision arthroplasty with a long stem implant would be the ideal choice. Cement fixation can be utilized in the presence of osteoporotic bone, but care must be taken to prevent cement extrusion into the fracture site. In this case, the stem is well fixed and revision arthroplasty is unnecessary.

Answer 2: Revision arthroplasty is indicated in a loose stem, but in this case, the stem is well fixed.

Answer 4: Lag screw fixation is not recommended with these fractures. Current data suggest good outcomes with hybrid locking plates and cerclage cables.

Answer 5: Type C fractures may be amenable to nonoperative treatment. However, when there is involvement near the stem tip there is a high risk of nonunion without adequate fixation due to poor endosteal blood flow in this region.

78) A 21-year-old college baseball pitcher presents with right elbow pain. He reports that his pitching velocity and accuracy has been decreasing. On physical exam, he has a positive moving valgus stress test. His lateral radiograph is shown in Figure A. Which of the structures in Figure B is likely injured?

1. A

2. B

3. C

4. D

5. E

Corrent answer: 3

The patient has valgus instability, which usually involves injury to the anterior oblique band of the medial ulnar collateral ligament, which is labeled C in Figure B.

Medial ulnar collateral ligament injuries can result from an elbow dislocation or from overuse. Overuse injuries are commonly seen in baseball pitchers, as a significant valgus stress is placed on the elbow in the late cocking and early acceleration phase of throwing. Microtrauma from repetitive valgus stress eventually leads to rupture of the anterior band of the medial UCL. Injury to the ulnar collateral ligament is characterized by the loss of velocity, ulnar side elbow pain, and a positive moving valgus stress test.

Cain et al. performed a review on ulnar collateral ligament reconstruction. They report that good results have been achieved with UCL reconstruction. In particular, throwers are able to return to the same or even higher levels of competition in the majority of cases.

Whiteside et al. published a study on the predictors of ulnar collateral ligament reconstruction in major league baseball players. They found 6 significant predictors of UCL reconstruction: (1) fewer days between consecutive games, (2) a smaller repertoire of pitches, (3) a less pronounced horizontal release location, (4) a smaller stature, (5) greater mean pitch speed, and (6) greater mean pitch counts per game.

Figure A is a normal lateral radiograph of the elbow. Figure B is a diagram depicting the ligaments of the medial elbow: (A) annular ligament, (B) radial collateral ligament, (C) anterior band of the medial UCL, (D) transverse band of the medial UCL, and (E) posterior band of the medial UCL.

Incorrect Answers:

Answers 1, 2, 4, and 5: The anterior band of the medial ulnar collateral ligament (C) is the likely source of the patient's pain.

79) A 19-year-old right hand dominant collegiate pitcher presents for worsening right shoulder pain and decreased velocity. On physical exam, he has decreased internal rotation but increased external rotation on his right compared to left side. He has pain and tenderness over his coracoid. An MRI arthrogram is performed and is normal. Which of the following is the next best step in management?

1. Weighted ball throwing program

2. Subacromial steroid injection

3. Arthroscopic biceps tenodesis and subacromial decompression 4. Arthoscopic capsular release

5. Pectoralis minor stretching and sleeper stretches

Corrent answer: 5

The best treatment for overhead athletes with glenohumeral internal rotation deficit (GIRD) is periscapular muscle (pectoralis minor) and posterior capsular stretching (sleeper stretches).

GIRD in overhead throwing athletes can lead to sport-specific limitation and significant pain. The most effective first-line treatment includes stretching of the posterior capsule and periscapular muscles. These patients may develop

"SICK scapula syndrome" (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement. The pectoralis minor tendon can contract secondary to scapular malpositioning, leading to significant tendonitis and pain.

Tyler et al. studied 22 patients with internal impingement to see if improvements in GIRD or posterior shoulder tightness was associated with a decrease in symptoms. They found a greater improvement of posterior shoulder tightness in patients with full resolution of their symptoms compared to patients with residual symptoms. They concluded that improvement in symptoms of internal impingement after physical therapy is related to an improvement in posterior shoulder tightness and not improvements in GIRD.

Kibler et al. described an approach to shoulder rehabilitation that integrates a physiologic and biomechanical framework of the kinetic chain model. They discuss a proximal to distal segment kinetic chain model for the throwing athlete. They state that scapular control coupled with rotator cuff activation is vital for normal shoulder function.

Illustration A shows an example of the sleeper stretches.

Incorrect Answers:

Answer 1: A weighted ball throwing program would not afford the proper stretching and scapular stabilizing exercises and may worsen symptoms. Answer 2: Although a steroid would be an eventual option, it would not be the first line of treatment for GIRD.

Answer 3 & 4: Any arthroscopic procedure for GIRD should be reserved for extremely severe cases as patients often improve with the proper rehab programs alone.

80) A 55-year-old male with a history of right shoulder osteoarthritis underwent a total shoulder arthroplasty 7 months ago. The patient now complains of right shoulder pain, instability, and weakness. He denies any falls or other trauma since surgery. Physical exam is notable for weakness with the belly-press test and external rotation of the right shoulder to 110 degrees compared to 80 on the contralateral side. His radiograph is shown in Figure A. What is the likely cause of this patient's symptoms?

1. Supraspinatus tear

2. Missed intraoperative periprosthetic humeral shaft fracture 3. Glenoid component malpositioning

4. Lesser tuberosity nonunion

5. Oversizing of the humeral head

Corrent answer: 4

The patient is presenting with increased pain and weakness due to lesser tuberosity nonunion following total shoulder arthroplasty.

Total shoulder arthroplasty performed through a standard deltopectoral incision requires takedown of the subscapularis in order to access the glenohumeral joint. Options for takedown include tenotomy of the subscapularis tendon, subscapularis peel, or lesser tuberosity osteotomy, which has gained interest due to the higher biomechanical strength of bone to-bone healing. Nonunion of the lesser tuberosity osteotomy can lead to very poor outcomes for affected patients, with many requiring several revision procedures.

Shi et al. report a case series of patients that had nonunion of the lesser tuberosity osteotomy following total shoulder arthroplasty. The authors found there were poor clinical outcomes in these patients with few presenting with a history of trauma and most requiring revision to reverse total shoulder arthroplasty. They recommended augmenting the lesser tuberosity repairs with a tension band construct in high-risk patients at the time of the index procedure.

Small et al. performed a review of a large series of patients undergoing a lesser tuberosity osteotomy for total shoulder arthroplasty. The authors found there to be an 11% nonunion rate of the osteotomy, with young males being at higher risk. The authors recommend the use of orthogonal radiographs when assessing the union of the lesser tuberosity osteotomy and that younger fit males must be reminded to follow postoperative protocols.

Matsen et al. performed a review of glenoid component failure in total shoulder arthroplasty. The authors reported that conforming articular surfaces and flat bone cuts contribute to the "rocking-horse" failure mechanism. They also reported that the presence of radiolucent lines adjacent to the glenoid component is associated with increased failure rates.

Steinmann et al. reviewed the treatment of periprosthetic humeral shaft fractures. Loose prostheses necessitate revision long stem component with supplementary fixation, whereas well-fixed stems with fractures at the tip or proximal require hybrid plate fixation. Fractures distal to the tip can be treated non-operatively, but in the presence of nonunion may require plate fixation with or without allograft struts.

Figure A demonstrates an axillary radiograph of the right shoulder with a nonunion of the lesser tuberosity. Illustration A depicts the Wright and Cofield

classification for periprosthetic humeral shaft fractures. Illustration B depicts a diagram detailing the rocking horse mechanism of glenoid component failure.

Incorrect Answers:

Answer 1, 2, 3, 5: These can all cause symptoms of weakness, pain, decreased range of motion, and instability following total shoulder arthroplasty; however, this patient's radiograph demonstrates nonunion of the lesser tuberosity, which is consistent with the patient's physical exam.

81) A 17-year-old gymnast comes to your clinic reporting multiple atraumatic shoulder dislocation events. She has been able to reduce her shoulder on her own without a single trip to the emergency department. Radiographs are normal and an MRI arthrogram is seen in Figure A. Which of the following physical exam findings is most likely to be present?

1. Cross-body adduction test

2. O'Brien's Test

3. Axillary Webbing

4. Jobe’s Test

5. Increased external rotation in adduction

Corrent answer: 5

In patients with multidirectional instability (MDI) a common physical exam finding is increased external rotation in adduction.

Multidirectional instability (MDI) is felt to arise from generalized ligamentous laxity and an incompetent rotator interval. Patients will often present with a history of atraumatic shoulder instability events that were easily reduced. Diagnosis often includes a thorough evaluation of systemic laxity (Beighton's score) as well as multidirectional shoulder instability (posterior, anterior, and

inferior). The exam finding of an increase in external rotation in adduction corresponds with an incompetent rotator interval. The mainstay of treatment is physical therapy with surgical stabilization reserved for recalcitrant cases.

Schenk et al. review MDI diagnosis and management. They state the pathophysiology stems from a patulous inferior capsule as well as a defect in the rotator interval. They state generalize ligamentous laxity occurs in 45-75% of patients who ultimately undergo surgery for MRI. They describe the sulcus sign which represents inferior laxity and anterior/posterior laxity assess with the load-and-shift test.

Levine et al. discuss the treatment of a patient with MDI. They state patients with MDI may have increased external rotation in an adducted and 90 degrees abducted position. They mention being cautious throwing athletes with GIRD who will have increased ER but a corresponding decrease in IR. They state the majority of patients can be treated with nonoperative measures with 83% satisfactory results in patients with atraumatic instability.

Figure A shows a normal MRI arthrogram of the right shoulder

Incorrect Answers:

Answer 1: Cross-body adduction test elicits pain when there is an associated AC joint pathology.

Answer 2: O'Brien's test represents a possible SLAP tear when a deep pain is elicited.

Answer 3: Axillary webbing can be seen in the setting of a pectoralis major rupture.

Answer 4: Jobe's test elicits weakness or pain in the setting of supraspinatus pathology.

82) A 65-year-old male underwent a right total shoulder arthroplasty procedure 5 years ago and is presenting with increasing shoulder pain and weakness. The patient denies any recent falls, fevers, or chills. The patient is unable to abduct the arm beyond 30 degrees but can be assisted passively to 120 degrees. Physical exam demonstrates a positive belly-press test and Jobe's test, but negative Hornblower's test and normal external rotation strength with the arm at the side. Figures A and B are the current radiographs. Current ESR and CRP are 21 mm/hr and 1.2 g/L,respectively. What is the most likely cause of the patient's symptoms and associated risk factor?

1. Osteolysis; high congruity of the glenoid component

2. Glenoid component loosening; insufficient bone stock

3. Prosthetic joint infection; male with acne

4. Supraspinatus and subscapularis tear; overstuffing of the glenohumeral joint

5. Supraspinatus and infraspinatus tear; undiagnosed prior rotator cuff tear Corrent answer: 4

The patient is presenting with history and physical exam findings consistent supraspinatus and subscapularis tears and radiographs suggesting anterior and superior escape. This is likely due to overstuffing of the glenohumeral joint leading to attritional ruptures of the subscapularis and supraspinatus.

Anatomic total shoulder arthroplasty (TSA) is primarily used to treat glenohumeral osteoarthritis and reliant on an intact rotator cuff. Complications following TSA are glenoid loosening, humeral loosening, rotator cuff tears, stiffness, and infection. The presence of a rotator cuff tear after TSA compromises the function of the prosthesis and predisposes the patient to glenoid loosening. Subscapularis tears usually occur in the early post-op period after minor trauma that compromises the repair. Combined supraspinatus tears can occur after overstuffing the glenohumeral joint with oversized implants.

Matsen et al. reviewed the failure of the glenoid component following TSA. The authors reported that extensive bone loss can present as an infection, high glenoid component conformity, osteolysis, and bone necrosis. The authors recommended that bone loss following arthroplasty should warrant an infection work-up early in the presentation.

Miller et al. reported on a case series of patients presenting with a subscapularis tear following TSA. The authors found that prior shoulder surgery, arthritis of instability, and subscapularis lengthening procedures were associated with post-operative tears. The authors concluded that despite adequate surgical treatment and rehabilitation, patients tend to have poor functional outcomes

Figures A and B demonstrate AP and lateral radiographs of the right shoulder with apparent anterior and superior migration of the humeral component.

Incorrect answers:

Answer 1: Osteolysis in total shoulder arthroplasty is rare due to the larger particle size generated with shoulder arthroplasty implants, making it more difficult for macrophages to mount a RANK-RANKL reaction. Answer 2: Glenoid component loosening can cause shoulder pain symptoms, however, given the presence of weak rotator cuff muscles on the physical exam it is unlikely to be the cause of the patient's symptoms. Answer 3: The patient has normal inflammatory markers and the physical exam is more consistent with a rotator cuff tear.

Answer 5: The radiographs demonstrate anterior and superior escape of the humeral component suggesting incompetence of the supraspinatus and subscapularis tendons. Additionally, the physical exam findings of Jobe's and belly-press test suggest insufficiency of these muscles.

83) A 20-year-old female presents with recurrent anterior shoulder instability. Imaging is obtained and demonstrates a bony Bankart lesion involving 40% of the glenoid. A Laterjet procedure is planned for the patient. Which of the nerves in Figure A is most at risk during the planned procedure?

1. A

2. B

3. C

4. D

5. E

Corrent answer: 5

The patient is planned to undergo a Laterjet procedure, which places the musculocutaneous nerve (labeled E in Figure A) at highest risk for injury.

Patients with glenoid bone defects >20-25% have a high recurrence rate (>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling), iliac crest bone grafting, and distal tibial bone grafting. When performing a Laterjet procedure, the musculocutaneous nerve is the most commonly injured nerve and occurs due to instrumentation around the conjoint tendon. The musculocutaneous nerve passes through the coracobrachialis muscle and descends between the biceps brachii and brachialis muscles, giving rise to the lateral antebrachial cutaneous nerve (LACN). Injury to the musculocutaneous nerve results in weakness of the

biceps brachii muscle and a sensory deficit in the distribution of the LACN. The axillary nerve may also be injured during graft fixation in a Laterjet procedure, but its incidence is less common than musculocutaneous nerve injury.

Gupta et al. reviewed the complications of open and arthroscopic Latarjet procedures. Despite the promising results in addressing shoulder instability, they found that the rate of complications was between 15% and 30%. They report that the risk of neurovascular injury is reported as being between 1.4% and 10%, with the musculocutaneous nerve being the most commonly injured nerve due to instrumentation around the conjoint tendon.

Freehill et al. performed a cadaveric study to identify changes in the neurovascular anatomy after a Latarjet procedure. They found significant differences in the location of the musculocutaneous nerve in the superior-to inferior direction for both arm positions, notably lax and consistently overlapping musculocutaneous and axillary nerves, and an unchanged axillary artery location. They concluded that the Latarjet procedure resulted in consistent and clinically significant alterations in the anatomic relationships of the musculocutaneous and axillary nerves, which may make them vulnerable to injury during revision surgery.

Clavert et al. published a study on the relationships of the musculocutaneous nerve and the coracobrachialis during the Latarjet procedure. They found that injuries to the musculocutaneous nerve that occur during a Laterjet procedure were due to lengthening of the nerve and modification of the penetration angle of the nerve into the coracobrachialis. They also suggested that some motor nerve destined to the coracobrachialis might be damaged during the proximal medial release of the muscle after the detachment of the pectoralis minor muscle.

Figure A is a diagram of the neurovascular structures in the shoulder, including the axillary nerve (A), radial nerve (B), ulnar nerve (C), median nerve (D), and musculocutaneous nerve (E). Illustration A is the same diagram in Figure A with all structures labeled.

Incorrect Answers:

Answer 1: The axillary nerve can also be injured during a Latarjet procedure, especially during graft fixation, but its incidence is less common than musculocutaneous nerve injury.

Answers 2, 3, and 4: The radial nerve, ulnar nerve, and median nerve are less likely to be injured by the Latarjet procedure, due to their paths.

84) A collegiate javelin thrower presents complaining of medial elbow pain that is affecting her performance. Her imaging is seeing Figure A. Which ligament is likely affected, what arc of motion does it contribute stability, and where does it insert anatomically?

1. Anterior oblique bundle of the ulnar collateral ligament, 30-120 degrees of flexion, sublime tubercle

2. Posterior oblique bundle of the ulnar collateral ligament, greater than 90 degrees of flexion, sigmoid notch

3. Posterior oblique bundle of the ulnar collateral ligament, 30-120 degrees of flexion, sublime tubercle

4. Anterior oblique bundle of the ulnar collateral ligament, greater than 90 degrees of flexion, sigmoid notch

5. Anterior oblique bundle of the ulnar collateral ligament, 0 degrees of flexion, sublime tubercle

Corrent answer: 1

The anterior oblique bundle (AOL) of the ulnar collateral ligament (UCL) inserts onto the sublime tubercle of the ulna and provides elbow stability between 30- 120 degrees of flexion.

The ulnar collateral ligament complex is the primary soft tissue stabilizer of the elbow to valgus stress. It is composed of 3 bundles; of which the anterior oblique bundle is the most important to the overhead throwing motion. The AOL is the strongest bundle and is taut as the elbow flexes past 30 degrees. The AOL itself is compared of 3 distinct bundles (anterior, central, and posterior), of which the anterior contributes the most to AOL stability. The posterior oblique bundle (POL) is a fan-like thickening of the capsule that becomes taut as the elbow flexes well past 90 degrees. The transverse oblique ligament does not confer any stability to the elbow.

Callaway et al. evaluated the functional role of the individual UCL bundles to valgus elbow stability. They sequentially sectioned individual bundles of 28 cadaveric elbows and found the AOL contributed to valgus stability for 30-120 degrees of flexion and the POL contributed past 120 degrees. This finding clarified which bundle necessitated reconstruction in cases of valgus instability.

Dugas et al. reviewed UCL anatomy and its implication for surgical reconstruction. They describe the AOL originating from the anterior-inferior medial epicondyle and inserting onto the sublime tubercle of the ulna with an average footprint of 128 square millimeters. They state that though there are many methods for reconstructing this ligament, reproducing the native anatomy is essential for a stable elbow.

Figure A is a coronal T2 MRI sequence showing an ulnar collateral ligament torn from its ulnar attachment.

Illustration A demonstrates the origin and insertion of the AOL.

Incorrect Answers:

Answers 2 and 3: The posterior oblique bundle does not provide elbow stability through the range required of overhead throwing. Additionally, the POL inserts onto the sigmoid notch of the ulna.

Answer 4: The AOL inserts on the sublime tubercle.

Answer 5: The AOL confers the most stability from 30-120 degrees of elbow flexion.

85) A 69-year-old patient who underwent a right reverse total shoulder arthroplasty 2 years ago for rotator cuff arthropathy presents with mild right shoulder pain and stiffness. He denies any fevers, chills, or recent falls/trauma. A radiograph of the right shoulder is shown in Figure A. Which of the following has been implicated in the development of this condition and what are the potential negative sequelae?

1. Deltopectoral approach; no impact in functional outcomes 2. Inferior glenosphere placement; glenoid component loosening 3. Preoperative superior glenoid erosion; decreased ROM, strength, and Constant scores

4. Over-reaming of the glenoid; increased dislocation rates

5. Superolateral approach; increased incidence of aspetic loosening Corrent answer: 3

The patient is presenting with inferior scapular notching which preoperative superior glenoid erosion has been associated in the development and is correlated with decreased ROM, strength, and Constant scores.

Scapular notching in reverse total shoulder arthroplasty is a common finding and usually presents with 1-2 years from surgery. Inferior scapular notching is the most common form and is usually the result of the superior placement of the glenoid component and with inadequate inferior tilt. Rarely does scapular notching necessitate revision surgery, but has been implicated with decreased abduction and flexion ROM, post-operative strength, and patient-reported outcomes compared to patients without notching.

Lévigne et al. performed a multicenter retrospective review of scapular notching following reverse total shoulder arthroplasty. The authors found that notching was associated with superior glenoid erosion, increased activity

levels, and superolateral approach with clinical manifestations of decreased strength and anterior elevation of the shoulder. The authors concluded that the preoperative glenoid erosion should guide the reaming technique to ensure the ideal placement of the glenosphere.

Simovitch et al. performed a retrospective review of risk factors and clinical implications of scapular notching following reverse total shoulder arthroplasty. The authors found that inferior placement of the glenoid prosthesis with smaller scapular neck angle decreased the incidence of inferior spurs and was associated with improved patient-reported outcomes. The authors concluded that optimal glenosphere placement reduces inferior scapular notching and improves patient-reported outcomes.

Figure A demonstrates an AP radiograph of the right shoulder with a superiorly placed glenosphere and resultant inferior scapular notching.

Incorrect Answers:

Answer 1: The deltopectoral approach has not been associated with inferior scapular notching. However, the superolateral approach has been linked to inferior scapular notching. This is likely due to insufficiently inferior placement of the glenoid component as a function of the surgical exposure. Scapular notching has not been linked to detrimental patient outcomes. Answer 2: Inferior glenosphere placement has been shown to decrease the risk of inferior scapular notching. Further, inferior glenosphere placement has not been associated with glenoid loosening.

Answer 4: Over-reaming of the glenoid has not been shown to result in inferior scapular notching. Furthermore, inferior notching has not been shown to result in increased dislocation rates.

Answer 5: Superolateral approach has been associated with inferior scapular notching. Scapular notching has not been associated with increased rates of aseptic loosening.

86) When performing a routine reverse shoulder arthroplasty, which technique would increase the moment of the deltoid compared to the native, rotator cuff-deficient shoulder?

1. Using a glenosphere with 10 degree inferior tilt

2. Switching to more constrained polyethylene component

3. Switching to a humeral prosthesis with a smaller neck-shaft angle 4. Switching to a short-stemmed humeral component

5. Placing the glenosphere more inferiorly

Corrent answer: 5

By placing the glenosphere in a more inferior location, the moment of the deltoid is increased.

Reverse shoulder arthroplasty (RSA) differs from anatomic shoulder arthroplasty in that it places a hemispheric ball on the native glenoid side (glenosphere) and a stemmed socket/shell on the humerus. The center of rotation (COR) becomes fixed medially and inferiorly, thus lengthening the deltoid and placing all deltoid muscle fibers lateral to the COR. This optimizes its function and it becomes the primary mover of the shoulder. Any technique/design that moves the COR medial and/or inferior, or lengthens the deltoid will increase the deltoid moment and muscle efficiency.

Tashjian et al. evaluated the effect of a Grammont-style prosthesis and lateralized COR prosthesis on range of motion and the force required to elevate the arm. Though both designs medialized/inferiorized the COR, they reported variable effects on both outcome measures with changes in glenosphere diameter, glenosphere tilt, and humeral shell and insert offset. They also found adding inferior glenosphere tilt increased the abduction force and decreased the deltoid moment. These findings demonstrate the subtle but possibly significant effects of inter-system designs.

Langohr et al. evaluated the impact of glenosphere diameter on joint range of motion and abduction force. They noted a loss of internal rotation and increase in shoulder abduction force as diameters increased for both Grammont-style and lateralized-COR designs. These findings highlight the biomechanical advantage that a medialized/inferiorized COR provides in RSA.

Giles et al. investigated the effect of RSA design on shoulder abduction force and joint load. They found increased glenosphere size and polyethylene thickness increased the force required to abduct the shoulder and increased the overall joint load. Conversely, humeral lateralization decreased the shoulder abduction force. This shows that excessively sized polyethylene may negate the beneficial effect of lateral humeral offset.

Illustrations A and B show design differences between traditional Grammont style design (A) and a lateralized-COR design (B).

Incorrect Answers:

Answer 1- Inferior glenosphere tilt will decrease the deltoid moment, as shown by Tashjian et al

Answer 2- Using a more constrained polyethylene component shouldn't have any impact on the deltoid moment

Answer 3- Adding more varus to the humeral component will shorten the deltoid length

Answer 4- Using a shorter-stemmed component should not have an effect on the deltoid

87) A 63-year-old patient that underwent a hemiarthroplasty 6 years ago presents with increasing right shoulder pain. The patient denies any fevers or drainage from the previous incision. On exam, the patient has forward flexion to 100 degrees and abduction to 30 degrees. There is weakness with resisted external rotation with the arm at the side. Radiograph of the right shoulder is shown in Figure A. An MRI of the right shoulder is shown in Figure 2. What is the best treatment option?

1. 2-stage revision arthroplasty

2. Resection arthroplasty

3. Conversion to anatomic total shoulder arthroplasty 4. Conversion to a reverse total shoulder arthroplasty 5. Rotator cuff repair

Corrent answer: 4

The patient is presenting with a previous right shoulder hemiarthroplasty with subsequent rotator cuff tear and extensive muscular atrophy of the supraspinatus and infraspinatus. The best option would be a revision to a reverse total shoulder arthroplasty (RSA).

Hemiarthroplasty is an effective means to treat primary glenohumeral arthritis or 4-part proximal humerus fractures. Major reasons for revision are progressive glenoid degeneration and rotator cuff deficiency. Anterosuperior migration on radiographs is suggestive of a rotator cuff tear with deficiency of the coracoacromial ligament. Optimal treatment involves revision to a RSA as anatomic total shoulder arthroplasty requires competent rotator cuff muscles.

Muh et al. performed a retrospective review of patients undergoing resection arthroplasty for failed shoulder arthroplasty. The authors found that all patients undergoing resection arthroplasty had an improvement in pain, but decreased shoulder function compared to preoperative evaluation, with prior RSA having the worst functional outcome. The authors concluded that resection arthroplasty provides an effective means for pain palliation at the cost of function in failed shoulder arthroplasty.

Black et al. performed a retrospective study of outcomes following RSA performed in patients <65 years of age for either revision of failed shoulder arthroplasty or primary glenohumeral arthritis. The authors found that there were no differences in outcomes between either group with the exception of reported Subjective Shoulder Value scores. The authors concluded that RSA is an effective means for revising failed shoulder arthroplasty in patients <65 years of age.

Merolla et al. performed a retrospective study of outcomes after failed shoulder hemiarthroplasty revision to RSA. The authors found improvements in pain, mobility, and patient-reported outcomes with 93% implant survival at 5-years after revision to RSA. The authors concluded that good outcomes can be expected after revision to RSA after failed hemiarthroplasty.

Figure A demonstrates an AP radiograph of the right shoulder with superior migration of the hemiarthroplasty component. Figure B demonstrates a sagittal T1 MRI of the right shoulder with Goutallier grade 4 atrophy of the supraspinatus and infraspinatus.

Incorrect Answers:

Answer 1: The patient does not have findings suggesting an infection, thus a 2-stage revision arthroplasty is not indicated.

Answer 2: Resection arthroplasty is indicated for severe shoulder pain or persistent infections despite sufficient surgical alternatives. Answer 3: Anatomic total shoulder arthroplasty requires functional rotator cuff muscles. This would not be a good revision option.

Answer 5: Given the degree of supraspinatus and infraspinatus atrophy a rotator cuff repair is unlikely to be successful.

88) A 32-year-old patient presents with persistent right shoulder pain and weakness over the past 5 months. He is a professional baseball pitcher and has well-developed shoulder and arm musculature. Pain is reproducible with associated weakness upon resisted shoulder external rotation when abducted to 90 degrees. His imaging is shown in Figures A-C. Which muscle(s) is/are affected and what is the most likely etiology?

1. Supraspinatus and infraspinatus; suprascapular nerve compression at the suprascapular notch

2. Supscapularis; traction neurapraxia on the upper subscapular nerve 3. Infraspinatus; suprascapular nerve compression at the spinoglenoid notch 4. Teres minor; axillary nerve compression at the quadrilateral space 5. Infraspinatus; tendinopathy at the greater tuberosity insertion

Corrent answer: 4

The patient is presenting with persistent shoulder pain and teres minor weakness consistent with quadrilateral space syndrome.

Quadrilateral space syndrome is the result of pathological compression of the axillary nerve and posterior humeral circumflex artery. It occurs in the quadrilateral space, which is formed by the confluence of the teres minor superiorly, teres major inferiorly, long head of triceps medially, and the surgical neck of the humerus laterally. Compression of the axillary nerve leads to atrophy of the teres minor and in some cases the deltoid. Patients typically present with pain in the affected shoulder and weakness with external rotation with the arm abducted to 90 degrees.

Chafik et al. performed a cadaveric study looking at motor innervation of teres minor. The authors found that there are two anatomic variants of fascial envelopment of the teres minor with the primary motor nerve taking a highly angulated course at the level of the fascial sling. The authors concluded that a

stout fascial sling could be the cause of a motor nerve compression to the teres minor.

Kruse et al. performed a retrospective cohort study of patients that underwent surgical decompression of the nerve to the teres minor for isolated teres minor atrophy. The authors found that patients that underwent decompression noticed a significant improvement in pain as well as resolution of weakness demonstrated by Hornblower's test. The authors concluded that release of the fascial sling to the teres minor is an effective treatment for isolated teres minor atrophy.

Friend et al. performed a combined cadaver dissection of the axillary nerve and radiological study of isolated teres minor atrophy. The authors found many anatomical variations of the axillary nerve with various possible sites of compression and isolated cases of teres minor atrophy to be clinically distinct from cases of quadrilateral space syndrome. The authors concluded that isolated teres minor atrophy is common with an unclear etiology due to anatomical variations of the axillary nerve.

Figure A demonstrates a coronal T1 MRI of the shoulder with apparent fatty infiltration of the teres minor. Figure B is an axial T1 MRI of the shoulder with fatty infiltration of the deltoid. Figure C is a sagittal T1 MRI of the shoulder with fatty infiltration of the teres minor. Illustration A depicts the anatomy of the quadrilateral space.

Incorrect Answers:

Answer 1: Suprascapular nerve compression at the suprascapular notch will lead to atrophy of the supraspinatus and infraspinatus, which will cause weakness with shoulder abduction and external rotation with the arm at the side.

Answer 2: Atophy of the subscapularis due to neurapraxia is rare as it receives innervation from the upper and lower subscapular nerve

Answer 3: Infraspinatus atrophy can occur from a spinoglenoid cyst which will cause isolated external rotation weakness with the arm at the side. Answer 5: Infraspinatus atrophy can occur from a chronic tear with retraction. However, MRI of the shoulder does not suggest this.

89) A 20-year-old male college-level thrower complains of chronic right shoulder pain and has been prescribed formal physical therapy with stretches consisting of laying in the lateral position on the affected side with your arm forward flexed 90°, elbow flexed 90°, and pushing the ipsilateral forearm towards the table. What is the correct diagnosis and the associated physical examination finding?

1. Adhesive capsulitis; > 25° decrease in affected shoulder internal rotation compared to contralateral shoulder

2. Glenohumeral internal rotation deficit (GIRD); > 25° decrease in affected shoulder internal rotation compared to contralateral shoulder 3. Posterior labral tear; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder

4. Adhesive capsulitis; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder

5. GIRD; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder

Corrent answer: 2

The patient has glenohumeral internal rotation deficit (GIRD), a condition usually seen in throwing athletes that is characterized by a decrease in internal rotation of 25° or more of the affected shoulder compared to the contralateral side.

In patients with GIRD, initial treatment consists of rest from throwing as well as posterior capsular stretching. The sleeper stretch is a common way to stretch the posterior capsule. The stretch is performed in a lateral position on the table on the affected side with your arm forward flexed 90 degrees, elbow flexed 90°, and pushing the ipsilateral forearm towards the table, which increases shoulder internal rotation. The majority of patients with GIRD respond positively to sleeper stretches, with arthroscopic posterior capsular release or anterior stabilization only indicated for failure of nonoperative management.

Wilk et al. describe in a review article a multiphase rehabilitation and exercise program that restores shoulder range of motion, strength, and endurance, allowing for an early return to unrestricted sporting activity. They recommend that when true posterior capsular tightness is present, posterior mobilization efforts including sleeper stretches should be utilized to increase the pliability of the posterior capsule.

Braun et al. report in a review on shoulder injuries in the throwing athlete that the majority will respond to rehabilitation programs that emphasize stretching of the tight posterior capsule. In those patients unresponsive to conservative management, especially the older elite throwers, they recommend selective arthroscopic postero-inferior capsulotomy.

Illustration A demonstrates the sleeper stretch.

Incorrect Answers:

Answers 1 and 3: Adhesive capsulitis is characterized by global active and passive range of motion loss in the shoulder, and is not limited to internal rotation.

Answer 4: Posterior labral tears manifest as posterior instability. Answer 5: Clinically relevant GIRD classically manifests with internal rotation deficits of at least 25°, with some studies demonstrating deficits of up to 50°.

90) A 70-year-old right-hand dominant female presents to your office complaining of continued right shoulder pain 12 weeks after falling from a ladder, despite participating in a rigorous physical therapy program. She was initially reduced in the emergency department and her injury films are shown in Figures 1 and 2. On exam, she has weakness on active elevation and external rotation, but full passive range of motion and intact sensation. New radiographs reveal no acute osseous abnormalities and a concentric reduction. What is best next step and which diagnosis will most likely be revealed?

1. No additional testing, observation; residual chronic pain from shoulder dislocation

2. MRI brachial plexus; axillary nerve palsy

3. MRI cervical spine; C5 and C6 nerve root radiculopathy 4. MRI right shoulder; rotator cuff tear

5. Right upper extremity electromyography; axillary nerve palsy Corrent answer: 4

The patient is 70-year-old with chronic shoulder pain and weakness after a shoulder instability episode, with concurrent rotator cuff injury at the time of dislocation, which can best be diagnosed on MRI.

Glenohumeral instability occurs in a bimodal distribution, seen most commonly in patients younger than 40 years of age, followed by a second peak in patients over age 60 years. This latter cohort presents with more complex injury patterns, including rotator cuff tears and fractures. As such, the integrity of the rotator cuff musculature must be evaluated for these patients.

Robinson et al. evaluated the presence of rotator cuff injuries in patients over 40 years who presented with traumatic anterior glenohumeral dislocation in a prospective trauma database study. They found that female patients with an age of sixty years or older who were injured in low-energy falls were more likely to have a rotator cuff tear or a greater tuberosity fracture. They concluded and recommended careful evaluation of rotator cuff function for any elderly patient with a glenohumeral joint dislocation.

Murthi et al. reviewed glenohumeral dislocations in the older patient. They reported that older patients were more likely than younger patients to sustain injuries to the rotator cuff, axillary nerve, or brachial plexus. Additionally, rotator cuff injuries are significantly more common than nerve palsies, and these two entities may be confused for one another. They concluded that for older patients with persistent shoulder pain and dysfunction after dislocation, careful evaluation of rotator cuff pathology should be undertaken.

Figures 1 and 2 depict an AP and axillary lateral radiograph of the right shoulder with an anterior dislocation of the glenohumeral joint with a Hill Sachs impaction fracture, which is not an uncommon associated injury.

Incorrect Answers:

Answer 1: The patient has persistent pain and shoulder dysfunction 12 weeks after a shoulder instability episode and must be worked up for associated injuries. Observation alone is not acceptable.

Answers 2, 3, and 5: The patient maintains full sensation about the right upper extremity, which makes the diagnoses of axillary nerve palsy and cervical nerve root radiculopathy unlikely.

91) A latissimus dorsi tendon transfer is indicated for which of the following clinical scenarios?

1. A 30-year-old carpenter with MRI findings depicted in Figure A 2. A 70-year old carpenter with MRI findings depicted in Figure A 3. A 30-year old carpenter with MRI findings depicted in Figure B 4. A 70-year old carpenter with MRI findings depicted in Figure B 5. A 30-year old on disability following a prior injury with MRI findings in

Figure A

Corrent answer: 1

The optimal candidate for a latissimus dorsi tendon transfer is a young laborer with a massive posterosuperior rotator cuff tear, atrophy, and significant fatty infiltration.

A latissimus dorsi tendon transfer can be utilized in young active patients with a massive irreparable rotator cuff tear involving the supraspinatus and infraspinatus and without significant glenohumeral arthritis. In carefully selected patients, it has been reported to relieve pain and improve function, particularly if the deltoid and subscapularis muscles remain intact. Superior capsular reconstruction is another potential option for younger, more active patients. Finally, older patients with irreparable cuff tears may benefit from reverse shoulder arthroplasty, whereas younger patients present more of a clinical challenge.

Gerber et al. reviewed patients with irreparable rotator cuff tears treated with

latissimus dorsi transfer. They found that patients with an intact subscapularis demonstrated improvement in pain, range of motion, and strength postoperatively, while no improvement was noted in patients with a dysfunctional subscapularis. They concluded that a deficient subscapularis is a relative contraindication to latissimus dorsi transfer.

Iannotti et al. evaluated the clinical results of latissimus dorsi transfers in the setting of irreparable posterosuperior rotator cuff tears at 2 years postoperatively. They found that patients with good clinical results had a significantly better preoperative function in active forward flexion and external rotation compared with patients with poor results. They concluded that preoperative shoulder function and general shoulder strength influence the clinical outcomes of latissimus dorsi transfers.

Figure A demonstrates a coronal and sagittal T1 MRI with a massive rotator cuff tear with retraction and fatty infiltration of the muscle belly. Figure B demonstrates a coronal and sagittal shoulder MRI with a partial thickness rotator cuff tear and no fatty infiltration.

Incorrect Answers:

Answers 2 and 5: The optimal candidate for a latissimus dorsi transfer is a young and active laborer with an irreparable massive posterosuperior rotator cuff tear.

Answers 3 and 5: A patient with an acute partial thickness tear of the supraspinatus can be managed initially with physical therapy, with rotator cuff debridement and/or repair reserved for failure of nonoperative management.

92) A 12-year-old male pitcher has been complaining of shoulder pain in his dominant arm for 3 weeks. He describes that the pain occurs while throwing. On physical examination, he has tenderness to palpation over the proximal humerus and pain with external rotation of the shoulder with limited internal rotation compared to the contralateral side. Imaging is shown in Figure A. What is the next best step in treatment?

1. Cessation of throwing activities until completely asymptomatic and initiate physical therapy

2. Continue activity as tolerated and initiate physical therapy 3. Closed reduction and percutaneous pinning of the proximal humerus 4. Obtain magnetic resonance imaging (MRI) of the shoulder 5. Answers 2 and 4

Corrent answer: 1

physical therapy may be initiated before returning to sport.

Osbahr et al. performed a review of LLS. They report that LLS is most commonly seen in throwing athletes between 11 and 16 years of age. Clinical evaluation and radiographic imaging confirm the diagnosis. Prevention of developing LLS is most effectively performed by regulating the athletes' pitch count.

Smucny et al. performed a review of shoulder and elbow injuries in the adolescent athlete. They report with the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. They conclude that the LLS is best treated with throwing cessation until the pain completely resolves.

Figure A is a radiograph of the proximal humerus in a pediatric patient with physeal widening but no separation or fracture.

Incorrect Answers:

Answers 2 & 3: The treatment of LLS is throwing cessation until symptoms resolve.

Answers 4 & 5: An MRI is not necessary in making the diagnosis of LLS.

93) A 13-year-old baseball pitcher presents with persistent pain of the right shoulder over the last 2 years. He denies any antecedent trauma or dislocations. They report sensations of instability when performing activities with external rotation and abduction. Physical examination reveals an internal rotation deficit of 10 degrees on the right shoulder. The patient is able to hyperextend the elbows and knees to 12 degrees, can place both palms on the floor with knees fully extended, and hyperextend the small finger MCP joint past 90 degrees. There is a positive anterior and posterior load and shift test with a positive sulcus sign. What is the likely diagnosis and next best step in management?

1. Labral tear; MRI of the shoulder

2. Glenohumeral internal rotation deficit; sleeper stretches

3. Multidirectional instability; periscapular muscle training

4. SLAP tear; MRI arthrogram of the shoulder

5. Little leauger's shoulder; refrain from pitching for 3 months

Corrent answer: 3

The patient has physical exam findings of increased tissue elasticity which predisposes the patient to multidirectional instability (MDI). The first-line treatment for this is exhaustive physical therapy focusing on periscapular strengthening and rehabilitation.

MDI is the result of repetitive microtrauma or inherited ligamentous laxity. As a result, there is persistent shoulder pain with overhead activities and evidence of instability in multiple directions on a physical exam. Common physical exam findings include a positive anterior and posterior load and shift test, apprehension/relocation test, and sulcus sign. Patients may also demonstrate increased ligamentous laxity by Beighton's criteria. Initial treatment involves physical therapy for a minimum of 3-6 months focusing on periscapular strengthening and humeral head control training. Patients that are refractory may undergo an arthroscopic capsulorrhaphy.

Whitney-Lagen et al. performed a retrospective study on a consecutive series of patients undergoing arthroscopic plication for multidirectional instability without a labral lesion. There was a significant improvement in postoperative Oxford Instability Scores (OIS), but patients with a Beighton score greater than 4 were less likely to experience excellent OIS scores. They concluded that arthroscopic plication is an effective treatment for shoulder MDI without labral lesions who have failed conservative treatment.

Watson et al. performed a case series of patients undergoing guided 12-week exercise program for multidirectional instability of the shoulder. Significant improvements were seen in all clinical questionnaires, including the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Additionally, there were significant improvements in scapular muscle strength and scapular position at the end of the program. The authors concluded that conservative treatment for MDI enables good outcomes regarding patient-reported outcomes and muscular strength.

Watson et al. 2016 and 2017 detailed a rehabilitation program that stabilizes the glenohumeral joint in multidirectional instability. The authors detailed a six-step program that initiates with scapular and humeral head control, which usually requires retraining to maintain more superior rotation and posterior tilt of the scapula, followed by posterior musculature development. Then dynamic training begins with flexion control from 0-45 degrees, which is then superseded by sagittal and coronal plane control from 45-90 degrees. The program is finalized by isolated deltoid training and sports specific activities.

Illustration A depicts Beighton score criteria.

Incorrect answers:

Answer 1: A labral tear is unlikely given the lack of trauma or dislocation history and physical exam findings suggestive of increased tissue laxity, thus an MRI would not be indicated.

Answer 2: Glenohumeral internal rotation deficit is diagnosed when there is a 25-degree discrepancy to the contralateral side. Sleeper stretches would not address the cause of this patient's symptoms.

Answer 4: A SLAP tear can occur in throwing athletes, but given the physical exam findings, this patient likely has MDI.

Answer 5: Little leaguer's shoulder is a Salter-Harris I physeal injury that occurs in young pitchers with excessive pitch counts. His presentation is more consistent with MDI.

94) A 17-year-old basketball player presents to your office with persistent shoulder soreness following a fall during a game 2 months ago. Immediately following this incident, a teammate manipulated the shoulder, which resolved his pain and allowed him to finish the game. His current radiograph is shown in Figure A. Based on his MRI shown in Figure B, what structure is torn, what is the eponym for this lesion, and at what position does it most contribute to stability?

1. Anterior-inferior labrum, Bankart lesion, external rotation with shoulder abducted at 45°

2. Anterior-superior labrum, HAGL lesion, internal rotation with shoulder abducted at 90°

3. Posterior-inferior labrum, GLAD lesion, internal rotation with shoulder abducted at 45°

4. Anterior-inferior labrum, Bankart lesion, external rotation with shoulder abducted at 90°

5. Posterior-inferior labrum, ALPSA lesion, external rotation with shoulder abducted at 45°

Corrent answer: 4

The figure shows an anterior-inferior labral tear, termed a Bankart lesion. This structure restrains the shoulder from excessive external rotation with shoulder abduction at 90°.

Anterior shoulder instability is a common condition seen in both contact and non-contact sports. The anterior-inferior glenohumeral ligament (AIGHL) attaches the humerus to the anterior-inferior labrum and becomes taut when the shoulder is externally rotated and abducted to 90°. If sufficient force is applied, a spectrum of different pathologies may occur. Anterior-inferior labral avulsions (Bankart lesions), glenoid labral articular defects (GLAD), anterior labral periosteal sleeve avulsions (ALPSA), and humeral avulsion of the glenohumeral ligaments (HAGL lesions) are all products of a similar instability event. Recognition and repair of these lesions is essential when surgically addressing the unstable shoulder.

Itoigawa et al. reviewed glenohumeral anatomy and anatomic variants. They describe two different glenoid attachments of the AIGHL: the more common attachment to the labrum, and the less common pattern of direct glenoid neck attachment. This highlights the importance of a comprehensive understanding of the surgical anatomy in order to correctly address true shoulder pathology.

Clavert reviewed the spectrum of labral injuries across multiple different pathologic processes. Anterior to posterior tears of the superior labrum (SLAP) and poster-superior labral tears are encountered in overhead throwing athletes, while posterior tears are associated with posterior shoulder instability. The author does note the overlap of these lesions meaning the history and physical exam is essential to guide appropriate treatment.

Streubel et al. reviewed the management of specific pathology in anterior shoulder instability. In addition to the previously described ligamentous lesions, associated bone loss is not uncommon and adds extra complexity. They emphasize the need to recognize all pathoanatomy in the unstable shoulder in order to avoid recurrent instability episodes.

Figure A is a normal AP shoulder radiograph. Figure B is a fluid-sensitive axial MRI with a Bankart lesion and edema within the posterior humerus, most likely from a dislocation event. Illustration A shows the variable attachment of the

AIGHL described by Itoigawa and Itoi. Illustration B shows a HAGL lesion with fluid extravasating outside of the glenohumeral joint and a white arrow pointing to the portion of the glenohumeral ligament that was torn off the humerus. Illustration C demonstrates an ALPSA lesion.

Incorrect Answers:

Answer 1: The anterior-inferior labrum is taut in external rotation and 90° of abduction.

Answer 2: A HAGL lesion is not shown, and would best be seen on coronal sequences.

Answers 3 and 5: GLAD and ALPSA lesions are not pictured in the image and are associated with anterior labral tears.

95) A 52-year-old patient sustained a right anterior shoulder

dislocation after falling down a flight of stairs several months ago and remains symptomatic. Which of the following figures demonstrates the expected injury associated with this?

1. A

2. B

3. C

4. D

5. E

Corrent answer: 2

Anterior shoulder dislocations in patients older than 40 years may result in rotator cuff tears, with the supraspinatus tendon most commonly affected.

Anterior shoulder dislocation is typically the result of a traumatic event across all age groups. In patients older than 40 years of age, anterior dislocations may cause tears of the supraspinatus and infraspinatus tendons with or without the typical Bankart lesions seen in patients younger than 40 years of age. This is believed to be due to the degeneration of the supraspinatus and infraspinatus tendons and the resultant loss of elasticity of the tendons that occurs as patients age, which makes them more prone to rupture. As a result, persistent symptoms are more likely to be related to rotator cuff injury rather than recurrent instability that is seen with younger patients.

Robinson et al. performed a case series of patients undergoing arthroscopy after an initial traumatic anterior shoulder dislocation in patients older than 35 years of age. Arthroscopic findings included 64.3% with rotator cuff tears, 64.3% with Bankart lesions, 10.7% with HAGL lesions, 7.1% with ALPSA lesion, and all patients had Hill-Sachs lesion of various sizes. They concluded

that traumatic shoulder dislocations in older patients result in various pathologies that contribute to recurrent shoulder instability and pain.

Streubel et al. reviewed the literature regarding anterior glenohumeral instability. They reported that anterior shoulder dislocations in young patients commonly result in anteroinferior capsulolabral tears, also known as Bankart lesions, that inherently destabilize the shoulder. Further, dislocations may result in Hill-Sachs lesion which, is an impaction fracture of the superomedial humeral head due to compression on the anteroinferior glenoid rim. Referenced studies suggest arthroscopic Bankart repair if the Instability Severity Index Score (ISIS) < 7. Open surgical repair is recommended for ISIS scores >/= 7, HAGL lesions, Hill-Sachs lesions, and subscapularis tears.

Murthi et al. reviewed the literature regarding shoulder dislocations in older patients. The authors cited studies that reported a high incidence of rotator cuff tears, brachial plexus injuries, and axillary nerve injuries than younger patients with anterior dislocations. Studies support a better outcome with

patients that sustain a greater tuberosity fracture rather than massive rotator cuff tears, and patients outcomes are improved when rotator cuff tears are treated surgically. The literature supports a lower redislocation rate in these patients as the ligamentous stabilizing structures, such as the anteroinferior labrum and the inferior glenohumeral ligament, are not injured in these patients.

Figure A depicts an axial T1-weighted MRI of the shoulder with a posterior Bankart lesion. Figure B depicts a coronal T2-weighted MRI of the shoulder with a massive and retracted supraspinatus tendon tear. Figure C depicts a coronal T2-weighted MRI of the shoulder with a HAGL lesion. Figure D depicts a coronal T2-weighted MRI of the shoulder with a SLAP tear. Figure E depicts an axial T1-weighted MRI of the shoulder with a subscapularis tendon rupture. Illustration A depicts the criteria for ISIS scoring.

Incorrect Answers:

Answer 1: Posterior Bankart lesions are usually the result of posterior shoulder dislocations.

Answer 3: HAGL lesions occur when there is inferior glenohumeral ligament avulsion from the humerus. This injury is more commonly seen after dislocations in younger patients.

Answer 4: SLAP lesions are commonly seen in overhead and throwing athletes. Studies have not correlated SLAP tears with anterior shoulder dislocations. Answer 5: Subscapularis tendon tears are less commonly seen with anterior shoulder dislocations. They can be seen with posterior shoulder dislocations

due to the force vector of the dislocation and the tension placed on the subscapularis tendon.

96) A 27-year-old male reports right shoulder pain after sustaining a fall at work 3 weeks ago. He is found to have a rotator cuff injury with medial subluxation of the long head of the biceps tendon. Which of the nerves labeled in Figure A innervates the rotator cuff muscle that is likely injured in this patient?

1. A

2. B

3. C

4. D

5. E

Corrent answer: 2

Medial subluxation of the long head of the biceps tendon is associated with injury to the subscapularis, which is innervated by the upper and lower subscapular nerves (labeled B in Figure A).

Subscapularis tears were previously thought to be rare injuries of the rotator cuff; however, new evidence suggests a higher prevalence than previously thought. It usually presents as an acute avulsion in younger patients with a hyperabduction/external rotation injury or as an iatrogenic injury due to failure of repair. The subscapularis is innervated by the upper and lower subscapular nerves. The lower subscapular nerve also innervates the teres major.

Adams et al. performed a study to determine a systematic approach for diagnosing subscapularis tendon tears with preoperative MRI scans. They found that 88% of patients with biceps tendon subluxation were found to have subscapularis tears. They also found that 71% of patients with a combined supraspinatus/infraspinatus tear and 68% of patients with a long head of the biceps tendon tear were found to have subscapular tears.

Deutsch et al. published a study on the clinical diagnosis, magnetic resonance imaging findings, and operative treatment of traumatic tears of the subscapularis tendon. They found that pre-operative MRI detected all relevant subscapularis and bicep tendon lesions, as well as all cases of biceps subluxation or dislocation. They report that the axial image is often excluded on routine MRI examinations for suspected rotator cuff tears but is important in the evaluation of the subscspularis and biceps tendons.

Figure A is a diagram of the brachial plexus with the following nerves labeled: (A) suprascapular nerve, (B) upper and lower subscapular nerves, (C) middle subscapular/thoracodorsal nerve, (D) musculocutaneous nerve, (E) axillary nerve. Illustrations A-F are axial T1-weighted MRI images demonstrating the anatomy of the shoulder.

Incorrect Answers:

Answer 1: The suprascapular nerve innervates the supraspinatus and infraspinatus.

Answer 3: The middle subscapular nerve, also known as the thoracodorsal nerve, innervates the lattisimus dorsi.

Answer 4: The musculocutaneous nerve innervates the biceps, medial

brachialis, and coracobrachialis.

Answer 5: The axillary nerve innervates the teres minor and deltoid.

97) A 23-year-old man is experiencing valgus instability of the elbow after many consecutive seasons of pitching. Which anatomical structure is likely injured and during which phase of the throwing cycle depicted in Figure A will his symptoms be most likely reproduced?

1. Medial ulnar collateral ligament; B

2. Lateral ulnar collateral ligament; B

3. Medial ulnar collateral ligament; C

4. Lateral ulnar collateral ligament; C

5. Medial ulnar collateral ligament; E

Corrent answer: 3

The patient is experiencing valgus instability from injury to the medial ulnar collateral ligament (MUCL). His symptoms will most likely be reproduced and most pronounced during the late cocking phase of the throwing cycle, which is depicted by C in Figure A.

The phases of throwing begin with wind-up, followed by early cocking, late cocking, acceleration, deceleration, and ending with follow-through. Elbow valgus stress is greatest in the late cocking phase, and may result in injury to the MUCL. The rotator cuff sees the greatest stress during the deceleration phases as it eccentrically contracts to slow the arm.

Chalmers et al. reviewed pitching mechanics and injury to the shoulder and elbow. They reported that pitching motion is a kinetic chain, beginning with forces generated by the large muscles of the lower extremity and trunk during the wind-up phase, which are eventually transferred to the ball through the shoulder and elbow during the cocking and acceleration phases. They concluded that any alterations in this natural kinetic chain increases pitcher fatigue and may increase both shoulder and elbow torques and the risk for injury.

Escamilla et al. reviewed shoulder muscle recruitment patterns and related biomechanics during upper extremity sports. They reported that shoulder forces, torques, and muscle activity are generally greatest during the arm cocking and arm deceleration phases of throwing to help resist the high shoulder distractive forces, which results in most shoulder injuries occurring during these phases. They recommended complete understanding of muscle activity during upper extremity sports by physicians, therapists, trainers, and coaches in order to provide appropriate treatment, training, and rehabilitation

protocols to these athletes.

Limpisvasti et al. reviewed shoulder and elbow injuries in baseball. They reported that shoulder and elbow injuries occur as a result of the body's inability to properly coordinate motion segments during the pitching delivery, leading to anatomic changes structural damage in the young thrower. They recommended that in the young thrower, the key to avoiding injury is preventing overuse as well as rehabilitation protocols centered on optimizing pitching mechanics, core strength, scapular control, and joint range of motion.

Figure A demonstrates the phases of throwing (unlabeled).

Illustration A demonstrates the phases of throwing (labeled).

Incorrect Answers:

Answers 1 & 5: While the MUCL injury manifests as valgus instability, his symptoms will most likely be reproduced during the late cocking phase, not the early cocking (B) or deceleration (E) phase.

Answers 2 & 4: Lateral ulnar collateral ligament injuries manifest as varus instability.

98) A 69-year-old patient presents with the injury shown in Figures A and B. A deltopectoral approach is used for open reduction and internal fixation of the fracture. Which of the following is the most likely complication that might occur when cable fixation is placed 4 cm inferior to the insertion of the latissimus dorsi?

1. Iatrogenic median nerve injury

2. Axillary nerve neurapraxia

3. Subscapularis tendon injury

4. Iatrogenic radial nerve injury

5. Incarceration of the brachial artery

Corrent answer: 4

The patient is presenting with a periprosthetic humerus fracture that will require cerclage fixation, which can cause iatrogenic radial nerve injury when placed 4 cm inferior to the latissimus dorsi insertion.

Postoperative periprosthetic humerus fractures are relatively rare complications but pose treatment challenges due to the poor vascular supply at the vascular site due to the prosthetic tip. Surgically treating these fractures requires a cable plate construct in stable implants and revision to a long stem prosthesis in loose implants. Open reduction and internal fixation can potentially cause an iatrogenic radial nerve injury if the cables incarcerate the nerve when passed 4 cm distal from the inferior aspect of the latissimus dorsi insertion, which is the entrance to the spiral groove.

Fu et al. performed a cadaveric study looking at the relationship of the radial nerve as it passes into the spiral groove through a deltopectoral approach. The authors found that the radial nerve entered the proximal spiral groove approximately 13 cm from the coracoid process, 10 cm from the distal lesser tuberosity, 8 cm from the superior latissimus dorsi insertion, and 4 cm from the inferior latissimus dorsi insertion. The authors concluded that placement of a cerclage cable just inferior to the latissimus dorsi insertion will safely avoid an iatrogenic radial nerve palsy.

Bohsali et al. performed a systematic review of the literature regarding complications following shoulder arthroplasty. The authors reported an overall complication rate of 11% with periprosthetic fractures most frequently occurring intra-operatively for both anatomic and reverse shoulder arthroplasties. Post-operative periprosthetic fractures accounted for 6.6% and 1.2% of all complications in reverse and anatomic arthroplasties, respectively.

Figures A and B are the AP and scapular Y radiographs of the right shoulder with a periprosthetic fracture involving the metadiaphyseal region of the humerus with a reverse total shoulder arthroplasty implant. Illustration A is a diagram of the radial nerve as it courses through the spiral groove. Illustration B is a diagram detailing the muscle insertions of the upper extremity.

Incorrect Answers:

Answer 1: The median nerve is located in the medial septum just lateral to the brachial artery, making it less disposable to a cable injury.

Answer 2: The axillary nerve is proximal from where the cerclage cable would be inserted and would unlikely be affected.

Answer 3: The subscapularis tendon is much more proximal than the latissimus dorsi insertion and would be relatively safe from cable placement. Answer 5: The brachial artery is more superficial and anteromedial posing less risk from cable incarceration.

99) A 24-year-old football player presents with recurrent shoulder instability. An arthroscopic labral repair in isolation without a bony procedure would result in a higher failure rate if performed for which of the following imaging studies?

1. Figure A

2. Figure B

3. Figure C

4. Figure D

5. Figure E

Corrent answer: 4

The presence of a preoperative defect in the glenoid has been shown to portend failure when arthroscopic labral repair alone is performed for recurrent instability in high level athletes.

Fractures and bony defects of the glenoid are not uncommonly seen with shoulder dislocations. A bony Bankart lesion is a fracture of the anterior inferior glenoid. While there is no consensus on the most accurate technique for measuring glenoid bone loss, defects of 15-25% are considered biomechanically unstable, and thus many surgeons advocate for bony procedures to restore bone loss in these cases. However, note that some surgeons may consider bony procedures in higher level athletes with recurrent instability from bone loss below this threshold while lower demand patients may tolerate a higher threshold. Bony procedures include the Latarjet procedure or osseous augmentation with autograft or allograft. There is a high risk of failure when an arthroscopic soft tissue procedure is performed in isolation for high level athletes with recurrent shoulder instability. .

Di Giacomo et al. described the evolving concept of bipolar bone loss and the

Hill-Sachs lesion. They described a radiographic arthroscopic method that uses the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, in the presence or absence of concomitant anterior glenoid bone loss. They reported that if the Hill-Sachs lesion engages, it is called an "off-track" Hill-Sachs lesion; if it does not engage, it is an "on track" lesion. They concluded that conversion of an off-track Hill-Sachs lesion to an on-track Hill-Sachs lesion is essential in stabilizing the shoulder with anterior instability. They recommend the use of their proposed treatment paradigm with specific surgical criteria for all patients with anterior instability, both with and without bipolar bone loss.

Nakagawa et al. performed a study to investigate risk factors related to the postoperative recurrence of instability after arthroscopic Bankart repair in athletes. They reported that risk factors for postoperative recurrence of instability included playing rugby, age between 10 and 19 years at surgery, preoperative glenoid defect, small bone fragment of bony Bankart lesion, and capsular tear. They concluded that younger age at operation and preoperative glenoid defect with small or no bone fragment significantly influenced recurrent instability among competitive athletes.

Figure A demonstrates a small posterior labral tear with a spinoglenoid cyst. Figure B demonstrates a normal shoulder MRI. Figure C demonstrates a posterior labral tear. Figure D demonstrates anterior glenoid fracture and bone loss. Figure E demonstrates an anterior labral tear.

Incorrect Answers:

Answers 1: Arthroscopic labral repair with a cyst decompression would likely be successful in addressing the posterior labral tear with the spinoglenoid cyst. Answer 3 & 5: Arthroscopic labral repair would likely be successful in anterior and posterior labral tears without bony defects.

Answer 2: Figure B demonstrates a normal shoulder MRI.

100) A 55-year-old male patient presents with right shoulder pain that is worse with overhead activity. The patient works as a computer programmer and is a recreational swimmer and has noted worsening pain with his breaststroke. Figure A is the coronal T2 MRI arthrogram of the affected shoulder. The patient decides to undergo an arthroscopic repair. What factor is associated with repair failure?

1. Recreational swimmer

2. Age greater than 36 years

3. Male gender

4. Sedentary career

5. Snyder type 2 lesion

Corrent answer: 2

The patient is presenting with a Snyder type 2 Superior Labral from Anterior to Posterior (SLAP) tear. Labral repair failures have been associated with patient ages >36 years.

SLAP tears involve the superior labrum at the location of the long head of the biceps insertion and commonly occur in overhead athletes. Snyder type 2 tears are those with an unstable biceps anchor and frayed labrum. If a course of nonoperative treatment fails, these are amenable to labral reattachment to the glenoid. However there is a high failure rate those patients older than 36 years of age, which is often attributed to the biceps. Better results are seen with biceps tenodesis in this age group, done either arthroscopically or open.

Provencher et al. performed a prospective study of military patients with Synder type 2 SLAP lesion undergoing arthroscopic repair. The authors found there to be a 36.8% failure rate and a 28% revision rate with age >36 years being the only associated factor. They concluded that SLAP repair does provide improvement in shoulder scores, but outcomes are not as favorable in patients greater than 36 years.

Werner et al. performed a retrospective cohort study of patients undergoing either arthroscopic suprapectoral and open subpectoral biceps tenodesis for superior labrum and biceps lesions. There were no significant differences between the two techniques with respect to patient-reported outcomes, range of motion, and strength. The authors concluded that both open and arthroscopic tenodesis provide excellent clinical and functional outcomes.

Figure A is a coronal T2 MRI arthrogram with contrast invagination into the superior labrum consistent with a SLAP tear. Illustration A is a diagram of the Snyder classification.

Incorrect answers:

Answer 1: Recreational activity has not been associated with SLAP repair failure.

Answer 3: Gender has not been associated with SLAP repair failure. Answer 4: Sedentary occupation has not been associated with SLAP repair failure.

Answer 5: Snyder type 2 tears are the most amenable to repair of the labrum, with types 1 and 3 treated with debridement and type 4 with tenodesis.

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