Upper Limb

Elbow

Arthrodesis

Indications

 

Very few

- young labourer with severe disabling elbow pain

- trial in POP at 90o for 6 weeks

 

Poor function

- adjacent joints cannot compensate for loss of function

 

Contraindications

 

RA

- high failure rate especially flail elbow with poor bone stock

 

Arthroplasty

Indications

 

RA 

- very good results

- 97% 10 year survival Coonrad-Morrey prosthesis

 

Other Dx 

- OA / post-traumatic arthritis / nonunion

- tend to have worse survival than RA

 

Haemophilia

- elbow joint commonly involved

- 90% of haemophiliacs

 

Acute unreconstructable fracture > 60

 

Contra-indications

 

Sepsis

 

Poor soft tissue cover skin triceps

 

Under 60 years

 

Charcot Joint

 

Implant Types

 

1. Fully Constrained 

- have highest failure

 

2. Semi- constrained 

 

Coonrad-Morrey TER

- sloppy hinge

- allow some varus-valgus

 

3. Unconstrained 

 

Design

- stems on ulna & humerus to prevent loosening

- poly / metal bearing

- require MCL & LCL for stability

 

Technique Latitude Total Elbow Replacement

 

Total Elbow Latitude RATotal Elbow Latitude RA

 

Design

- can covert unlinked to linked simply at end of case or at later revision by adding anterior O piece

- unconstrained / semiconstrained

- anterior humeral flange with bone graft important for longetivity

 

Lateral position

- arm over bolster

 

Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve with vessiloops

 

Total Elbow Ulna Nerve

 

Triceps Options

 

A. Split in midline

- feathered off bone medially and laterally

- left attached distally

 

B.  Bryan-Morrey

- triceps elevated from subperiosteally

- from ulna to radial side

- periosteum left attached on radial side

 

C.  Triceps sparing

- elevate triceps tendon medially and laterally

- identify and protect ulna and radial nerve medially and laterally

- divide collaterals from humerus and dislocate elbow to medial aspect of triceps

 

Distal Humerus

- elevate and tag LCL / MCL for later repair

- elevate anterior capsule off humerus

 

Dislocate Elbow

 

Prepare humerus

 

1.  Size capitellum and trochlea with spool

- judge off distal humerus

- insert into olecranon and over radial head

 

2.  Stabilise centre of rotation

- most important

- centre of capitellum to medial epicondyle of trochlea (just distal and anterior to it)

- pass pin through

 

3.  Resect olecranon fossa, find entry to IM canal

- pass IM guide

 

4.  Attach resection jig to rotation and IM pins

5.  Drill holes made to establish area to resect with saw

6.  Need to leave medial column (some trochlea) and lateral column (some capitellum)

7.  Trial

 

Prepare ulna and radius

 

1.  Broach IM canal of ulna

2.  Pass IM jig, centre on ulna

- EM points towards ulna styloid

- fixed in position with 3 pins

3.  Use jig to 

- resect radial head

- burr prepares ulna lateral to medial

4.  Trial

 

Humeral / ulna and radius prosthesis inserted

- simplex cement

- cement restrictors

 

Closure

- collateral ligaments reattached through humeral prosthesis

- closure triceps over drain with Ethibond

 

Post op

- POP 1 - 2 weeks till wound healed

 

Results

 

Morrey et al JBJS Am 1998

- TER in rheumatoid arthritis

- followed for 10 years

- 92% survival rate

- 10% incidence of serious complication requiring re-operation

- infection / aseptic loosening / fracture / triceps avulsion / loosening

 

Morrey et al JBJS Am 2010

- TER in post traumatic arthritis

- 69 patients followed for 9 years

- 19% failure rate

- infection < 5 years, bushing failure 5-10 years, then component loosening

- most patients with failure < 60 years

 

Complications

 

Infection

 

Total Elbow Replacement InfectionTotal Elbow Joint Infected 2Infected TER

 

Incidence

- 4-5%

- most common cause of failure

 

Risk factors for infection

- previous surgery

- previous infection

- stage IV RA

- drainage post-op

- re-operation for any reason

- poor skin

 

Prevention

- Bier's block and IV antibiotics at beginning of case

- POP for 2 weeks post op to achieve wound healing

 

Management

 

Often follows superficial infection or bursitis

- need aggressive treatment of any superficial infection

- can often salvage joint with early debridement and washout

 

If signs of bony infection / loosening 

- 2 stage revision

- resection arthroplasty

 

Total Elbow Replacement Cement SpacerTotal Elbow Replacement Cement Spacer 2

 

Intraoperative fracture

 

Instability

 

More common in unconstrained

- 6%

 

Transient neuropraxia

- 5%

 

Triceps failure

- 2%

 

Loosening

 

Revision TER

 

Total elbow loose humeral component

 

 

 

 

Arthroscopy

Indications

 

1. Removal Loose body

 

Elbow scope Loose Body

 

2. Excison of osteophytes

- coronoid

- olecranon

- aiming to improve ROM / prevent impingement

 

Elbow Stiffness Posterior ImpingementElbow Stiffness Posterior Debridement

 

3. Elbow Stiffness Capsular Release

- capsular contraction can limit range

- anterior capsulotomy

- risk to median nerve anteriorly

 

4. Management OCD lesions

 

Elbow scope Radial Head OCDElbow OCD

 

5.  Synovectomy

- RA, haemophilia

- usually results in marked blood loss

- leave portals open to allow for drainage to prevent haemarthrosis and stiffness

 

6.  Washout sepsis

 

7. Excision of Radial Head

- useful combined with synovectomy in RA

- can excise head and 2-3mm of neck

- to ensure stability should keep annular ligament

 

Contra-indications

 

Abnormal elbow scarring

Extensive HO

Previous ulna nerve transposition

 

Technique

 

Equipment

 

4mm scope 

2.7mm wrist scope

 

Position

 

A.  Patient lateral

- hip supports

- arm over L shaped bolster

 

Elbow Lateral Decubitus

 

B.  Patient supine

- anterior portals and arthroscopy with arm on arm board

- posterior portals and arthroscopy with arm bent over patient

 

Landmarks

 

Outline surface markings with a pen

- epicondyles, radial head, olecranon

- medial and lateral supracondylar ridge

- draw ulna nerve

 

PIN landmarks

- anterior to radial head

- posterior to mobile wad

 

Anterior elbow arthroscopy

 

Lateral portals

 

A.  Proximal Anterolateral portal

 

Uses

- intial viewing portal

 

Technique

- 1-2 cm proximal to lateral epicondyle

- just anterior to lateral intermuscular septum

- onto anterior humerus

- walk down into joint

- insufflate with 20 mls

- incision in skin

- same technique to insert portal

 

Issues

- radial nerve

- moved further away by insufflation

- most dangerous portal

- do first before swelling obscures anatomy

 

Elbow Arthroscopy Anterior Compartment

 

B.  Anterolateral Portal

 

Uses

- working portal

- microfracture capitellar OCD

 

Technique

- just in front of lateral epicondyle / anterior to radial head

- in sulcus between radial head and capitellum

- PIN most in danger here

- avoid distal / anterior placement

 

Elbow Arthroscopy AnterolateralElbow Scope Anterolateral Portal

 

Medial Portals

 

Proximal Anteromedial Portal 

 

Anatomy

- 2cm proximal to the medial epicondyle

- just anterior to humerus / medial intermuscular septum

- ulna nerve behing medial epicondyle

- median nerve and brachial artery anterior

 

Technique

- insert needle under vision

- incision in skin

- pass haemostat under vision

 

Elbow Scope Anterolateral Portal

 

Uses

- removal of loose body

- visualise chondral surfaces ulnohumeral and radiocapitellar

 

Anteromedial portal

 

Anatomy

- 2cm anterior and 2cm distal to medial epicondyle

 

Posterior elbow arthroscopy

 

Indication

 

Posterior loose bodies

Olecranon tip / fossa impingement

Retrograde capitellum OCD drilling

 

Danger

- ulnar nerve when debriding medially

 

Portals

 

Posterocentral portal

- 3 cm proximal to tip olecranon

- in midline

 

Posterolateral portals

 

Technique

- 2 - 3 cm proximal to tip olecranon

- in line lateral edge of triceps

 

Soft spot portal

 

Anconeus triangle

- olecranon tip / radial head / lateral epicondyle

- through skin, anconeus, capsule

 

Danger

- posterior cutaneous nerve

 

Uses

- retrograde drilling of capitellum

 

Elbow Arthroscopy Posterior CompartmentElbow Arthroscopy Medial CompartmentElbow Arthroscopy PosterolateralElbow Arthroscopy Posterolateral 2

 

Complications

 

Nerve injuries

 

All nerves at risk especially PIN

 

Always

- no LA

- minimise tourniquet time

- minimise pump pressure to 40

 

If PIN palsy post op

- need to explore

- usually cut

- very difficult to defend medicolegally

- only do elbow arthroscopy if trained in it and have done cadaver course

 

Vascular injury

 

Haemarthrosis

 

Stiffness

 

Infection

 

 

 

 

Capitellar OCD

Epidemiology

 

Adolescents & young adults

 

Usually between 12 - 21 years 

 

Throwing athletes / gymnasts

 

Little Leaguer's Elbow

- combination of capitellar OCD and MCL injury

- a repetitive throwing injury / seen in pitchers

 

Aetiology

 

1.  Trauma & Overuse

 

Common throwing sports / gymnastics

- dominant limb predominates

- repetitive overuse

- valgus overload on radiocapitellar joint 

- fatigue failure of the subchondral area 

- overlying cartilage fails under shear stress & separates

 

Capitellum loaded more heavily

- less able to take load than radial head articular surface

- especially if have some slight eccentric loading which can occur in throwing athlete or gymnast

 

2.  Ischaemia

 

Predominant blood supply to capitellum from posterior vessels

- histopathology shows osteonecrosis

 

Pappas Classification   

 

Category 1  - patients < 13 years of age 

Category 2  - 13 years to adulthood 

Category 3  - adults 

 

Found better prognosis with younger patients 

- especially with open capitellar growth plate

- respond better to non operative treatment

 

Symptoms

 

Dominant arm / history of over-use

 

Pain activity related

 

Limited range

- very common presentation

 

Clicking, grinding, catching, locking

- ? Loose bodies

 

Examination

 

Tender over lateral aspect elbow

 

Loss of extension

 

Radio-capitellar compression test

- active supination and pronation with arm fully extended

 

Examine MCL

 

Iwase's Classification Xray

 

Grade 1

- localised flattening and translucency

 

Capitellar OCDElbow OCD

 

Grade 2

 

A:  Small fragment without sclerosis

B:  Small fragment with sclerosis

 

Elbow OCD Type 2BElbow OCD Type 2B CT

 

Grade 3

- in situ loose body

 

DDx

 

Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellum involved

- not sure if is earlier spectrum of same disease

 

MRI

 

Fluid interface denotes detachment / instability

 

Capitellar OCD MRI

 

Management

 

Non Operative

 

Indications

 

Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD

 

Option

 

Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months

 

Results

 

Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

- healing of lesion in 16/17 patients with open growth plates

- healing of lesion in 11/22 with closed growth plates

- 25/30 early stage lesions healed

- only 1/9 advanced stage lesions healed (Grade 2A and Grade 3)

- suggest early surgical intervention in advanced OCD

- recommend surgical intervention if no sign of healingin 3-6 months

 

Operative

 

Indications

 

1.  Failure non operative treatment

2.  Loose bodies

3.  Instability / displacement

 

Large / salvageable fragments

 

A.  Stable / Drill in situ

 

Elbow OCD InsituElbow OCD Retrograde Drilling

 

Arthroscopic technique

- anterograge via anterolateral portal if possible

- retrograde via ACL jig / posterolateral portal with elbow flexed

 

B.  Unstable / Fixation

 

Arthroscopic technique

- via soft spot portal

 

Takahara et al JBJS Am 2007

- demonstrated fragment fixation or reconstruction better than removal

- fragment fixation with bone graft

 

Small / unsalvageable Fragments

 

A. Arthroscopic Debridement

 

Elbow Scope Capitellar OCDElbow Scope OCD Debridement

 

Schoch et al Arthroscopy 2010

- arthroscopic debridement in 13 patients

- follow up average 3 years

- symptomatic relief

- 6/13 had to cease some sport

 

B.  Microfracture

 

Elbow Scope OCDElbow scope OCD Microfracture

 

C.  Abrasion

 

Elbow OCDElbow OCD Abrasion

 

Large Chondral Defects

 

A.  Mosaicplasty

 

Ovesen et al J Should Elbow Surg 2011

- 10 patients treated with mosaicplasty

- average age 21

- incorporation in all patients

- significant improvement in Mayo elbow scores

 

B.  MACI

 

Coronoid Process Fracture

BackgroundClassification Coronoid Fractures

 

The coronoid is the most important portion of ulno-humeral articulation

 

Reasons

1.  Provides anterior buttress

2.  Anterior capsule and brachialis attach to coronoid

2.  Anterior band of the MCL attaches to it

- distally and medially on sublime tubercle

 

Instability rises and prognosis deteriorates according to the amount of coronoid process that is fractured

 

Fracture patterns

 

Transverse

Anteromedial facet fragment

 

Mechanism

 

Most commonly associated with elbow dislocations

Anteromedial facet fractures may be caused by varus / rotational force

 

Regan and Morrey Classification

 

Coronoid Process Classification

 

Type I 

- usually stable

- shear fracture not avulsion fracture

- may rarely cause residual instability in elbow dislocation

 

Coronoid Fracture Type 1Coronoid Fracture Type 1 CT

 

Type II 

- 50% coronoid

- elbow usually unstable

- lose attachment of capsule

- ORIF screws or sutures

- any ? about stability use hinged fixator

 

Coronoid Fracture Type 2

 

Type III

- > 50% coronoid

- Uncommon

- unstable as lose capsule +/- MCL with anteromedial fragment

- ORIF with screw / sutures / anteromedial buttress plate

- again may need hinged fixator

 

Type 3 Coronoid FractureCoronoid Fracture Type 3

 

Operative Management

 

Surgical approach

 

1.  Universal posterior approach

- if performing surgery for complex dislocation

- allows medial and lateral access to joint

 

2.  Lateral approach through radial head

- if excising radial head, then replacing

 

3.  Medial approach

- isolate and protect ulna nerve  

- elevation of ulna origin of flexor pronator group anterior to FCU

- important if fracture is anteromedial

 

4.  Approach through fractured olecranon

 

Options

 

Type 1

- capsular suture repair

 

Type 2 / 3

A.  Screws (AP or PA)

B.  Pass sutures through capsule and tie over drill holes in ulna

 

Anteromedial fragment

- medial approach / buttress plate

 

Coronoid Process Buttress Plate

 

Unrepairable / unstable

- reconstruct with radial head, iliac crest, or allograft

 

Cubitus Varus

Incidence

 

Occurs 10% of supracondylar humeral fractures

- varus malunion

 

Lateral condyle fracture

- AVN trochlea

 

Elbow Cubitus Varus

 

Growth arrest of medial aspect physis

- rare

- post traumatic

 

Effects

 

Usually little functional defect

 

Cosmetic problem

- appearance can be unacceptable to parents and child

 

NHx

 

Does not correct with time

 

Operative Management

 

1.  Lateral closing wedge osteotomy of the supracondylar region 

- perform at skeletal maturity

- metaphyseal not diaphyseal

- preserve medial cortex

- beware abnormal position of radial nerve (passes through callous)

- 1mm of wedge for each degree

- fixation with plate

 

2.  Complex Osteotomies

- posterior approach

- bilateral plates

- for severe deformities

 

Elbow post distal Osteotomy

 

3.  Young patient / open physis

- guided growth

- application lateral 8 plate

 

 

 

Dislocation

Anatomy Pathology

EpidemiologyElbow Dislocation LateralComplex Elbow Dislocation AP

 

6 /100 000

- second most common dislocation after shoulder

 

Mechanism

 

FOOSH

 

Goal

 

1.  Obtain and maintain a concentric reduction 

2.  Achieve a painless and functional ROM

 

Associated Injuries

 

20% neuropraxia (ulna nerve / AIN)

 

Classification

 

Final position of Ulna Relative to Humerus

 

Posterior

Posterolateral

 

Degree

 

1.  Complete 

 

2.  Subluxed / Perched (Drop sign)

- < 10 % patients

 

Simple / Complex

 

25-50% associated with fracture

 

Timing

 

Acute / Chronic / Recurrent

 

Bony Anatomy

 

Ulnohumeral Joint

 

Trochlea and ulna highly conformed

- trochlea covered by cartilage in arc 300o

- trochlea separated from the capitellum by groove in which rim of radial head articulates

- trochlea 6o valgus which creates carrying angle

 

Radiocapitellar Joint

 

60% of load at elbow

- concave radial head with capitellum

- posteromedial 2/3 articulates with sigmoid notch ulna

- anterolateral 1/3 has no cartilage /  safe zone

 

Anterior part of radial head fractures normally

- part of spectrum in dislocation

- radial head important secondary stabiliser, especially when MCL deficient

 

Radial head and neck form an angle of 15o with the shaft

 

Distal Humerus

 

Tilted anteriorly 30o in lateral plane

- 5o internally in transverse plane

- 6o of valgus in front plane

 

Elbow Valgus Carrying angleElbow Trochela Anterior Angulation

 

Centre of rotation

- trochlea

- centre of rotation offset anteriorly from humeral shaft

 

Elbow Centre of Rotation

 

LCL

 

LCL anatomy elbow

 

Action

- Varus Stability

 

LCL has 4 Components

 

1. Annular Ligament

- anterior edge supinator crest to posterior edge

 

2. Radial Collateral Ligament

- CEO to annular ligament

- fan-shaped

 

3. Lateral Ulna Collateral Ligament 

 

Most important restraint to PL instability

- CEO to supinator crest

 

Must protect in Kocher approach

- in line with edge of anconeus, deep to it

- must protect in surgical approach between anconeus and ECU

 

4.  Accessory Collateral Ligament

- from crest to diffusely over annular ligament

 

MCL

 

Elbow MCL

 

Action

- primary restraint to valgus stability

- especially in flexion

- this is the position in the throwing athlete

- in extension radial-capitellar joint important

 

3 parts

 

1. Anterior band

- CFO to sublime tubercle

- most important

 

2. Transverse band

- olecranon - sublime

- groove for ulna nerve

 

3. Posterior band

- CFO to olecranon

 

Constraints to Elbow Instability 

 

Primary Static

 

1.  Ulnohumeral articulation

- olecranon and coronoid

 

2.  MCL 

 

3.  LCL

 

Secondary Static

 

1.  Radio-capitellar joint

 

2.  CFO / EFO

 

3.  Capsule

 

Dynamic Stabilisers

 

Anconeus - PLR stability

 

Triceps / Brachialis / Biceps

 

Pathoanatomy / Horii circle

 

Begins on the lateral side, progresses to the medial side in three stages

- anterior band of MCL is the last torn

 

Stage 1

 

Damage to LCL

- Posterolateral Rotatory Subluxation

- this can reduce spontaneously

 

Stage 2

 

Damage to anterior and posterior capsule

- posterior capsule quite insignificant

- anterior important

 

Coronoid appears perched on trochlea

- incomplete PL dislocation

- concave medial edge of ulna on trochlea

- can be easily reduced or even by patient

 

Stage 3

 

Medial disruption

 

Stage 3A

 

Anterior band of MCL intact

- postero-lateral dislocation

- pivots about this anterior band

- often seen with radial head and coronoid fracture

 

Reduce with traction, varus and pronation

 

Maintain stability with hand pronated

- stability provided by anterior MCL

 

Stage 3B

 

Entire MCL disrupted

- varus / valgus / rotatory instability present after reduction

 

Need to be flexed > 30 - 40o to be stable

 

Stage 3C

 

Unstable at 90o

 

Entire distal humerus stripped / CFO / CEO

- reduction maintained only with flexion > 90o

 

Hinged External Fixator

External fixator elbow 1External Fixator Elbow 2

 

Indications

 

1.  Persistent instability despite ORIF and LCL repair

 

2.  Gross acute instability, not suitable for surgery

 

3.  Delayed treatment > 4 weeks

 

Compass hinge  / S&N

 

Compass Hinge Lateral XrayCompass Hinge AP Xray

 

Compass HInge Medial ClinicalCompass Hinge Clinical

 

Set up

- two incomplete rings proximal and distal

- hinge in centre

- can be used actively or passively

- adjustment wheel is medial (to use with other hand)

- rings posterior, open anteriorly

- rings compatible with ilizarov equipment

- hinge can also be adjusted in the varus valgus plane

- do so that distal ring is perpendicular to plane of ulna

 

Compass Hinge Centre of Rotation

 

Key is distal humeral axis

- imagine axis is in spool at end of humerus

- open laterally to identify capitellum

- open medially to identify trochlea

- confirm centre of rotation on lateral

 

A. Insert medial and lateral 3.5 mm pins partially

- place external fixator over pins but this can be difficult

- adjust pins so hinge slides easily over them

- insert pins 2mm

 

B.  Insert a single pin through axis of rotation

- slightly easier to apply the external hinge over the pin

- may not have to open the medial side as much

- only slight to identify and protect the ulna nerve

 

Medial Humeral half pin

- posterior to ulna nerve

- ensure proximal ring is perpendicular to humerus

- use two hole rancho cube with centering sleeve

- drop off undersurface off ring

- insert 5mm pin (drill, measure, insert HA pin by hand)

- need bicortical fixation

 

Lateral humeral pin

- anterior to radial nerve

- 2 hole post with single hole rancho

- allows angulation of pin from proximal to distal

- also angle posterior to anterior

 

Ulna pins

- 4mm pins into subcutaneous border

- must reduce elbow first and hold reduced whilst inserting pins

- ring must be perpendicular to ulna

- usually put elbow in 90 degrees of flexion

- proximal pin off proximal side of ring wth rancho cube

- bicortical usually into coronoid

- check is stable reduction

- insert second +/- third pin distally

Management

Acute Elbow Dislocation Management

Elbow Dislocation Lateral

 

1.  Reduction under IV / conscious sedation

- assistant applies traction in slight flexion

- second person corrects lateral displacement by manipulating olecranon medially

- flexion to 90o

 

2.  Post reduction assess stability

- stable if can extend to within 30 - 40o without instability

- if unstable, pronate forearm and see if can extend to within 30 - 40o (MCL intact)

- if unstable pronated with elbow < 45o extended, elbow will need surgery

 

3.  Confirm concentric reduction

- 2 view check x-rays mandatory

 

4.  Stable elbow

- manage in POP 90o 2 weeks

- weekly check xray

- then begin ROM exercises

 

Elbow ROM Brace

 

Management Problems

 

A. Simple Elbow Dislocation

 

B.  Complex Elbow Dislocation

- radial head fracture

- coronoid process fracture

- Terrible Triad (MCL / coronoid / radial head)

- olecranon fracture +/- radial head +/- coronoid

- capitellar fractures

 

Note

- difficult problem

- need to prepared at all times to

- ORIF / replace radial head

- repair / reconstruct LCL

- ORIF / suture coronoid

- repair MCL

- apply external fixator

 

1.  Simple Elbow Dislocation

 

A.  Stable Simple Elbow Dislocation

 

 Simple Elbow DislocationElbow Simple Dislocation Reduced

 

Management

 

Reduce

 

Assess Stability 

- OT if unstable > 45o in pronation

 

X-ray weekly

 

Mobilise 2 - 3 weeks

 

If FFD at 6/52 > 40o

- night extension splint

- turnbuckle elbow extension splints

 

Josefsson et al 1987 JBJS AM

- randomised 30 patients with elbow dislocations

- non-operative group 2 weeks in plaster at 90°

- operative group had ruptures of both collaterals / most had avulsions from the humeral epicondyles

- no difference in outcome between the two groups regardless of initial stability

- loss of extension was commonest complication

- seen 50% more in operative group

 

B.  Unstable simple elbow dislocation

 

Uncommon but not rare

- may be intact medially

- avulsed LCL and CEO

 

Algorithm

 

1.  Kocher approach & Reconstruct / Repair LCL + CEO

- lateral ulna collateral ligament is usually avulsed from lateral condyle

- centre of rotation is centre of capitellum

- place suture anchor

- repair anconeus and ECU over top

- +/- reconstruct / augment with slip Palmaris if required

- ROM brace

 

2.  Elbow still unstable / address MCL

- usually avulsed from medial epicondyle 

- usually can do direct repair / suture anchors

- mid-substance probably have to reconstruct with Palmaris

 

Medial approach centred on medial epicondyle

- locate, mobilise and protect ulna nerve

- proximally between brachialis and triceps

- distally between pronator teres and brachialis

- can reflect PT

- protect median nerve distally

 

C.  Chronic Simple Elbow dislocation

 

Missed injury / delayed presentation

- open reduction

- removal scar tissue

- repair / reconstruction LCL

- +/- hinged external fixation

 

2.  Dislocation with Radial Head Fracture

 

Manage as per radial head classification

 

Hotchkiss Modified Mason class (R&G)

 

Type I

 

Non / minimally (<2mm) displaced fracture of head 

- forearm rotation (pronation/supination) is limited only by acute pain and swelling 

- diagnose by LA injection and full pronation and supination

 

Non operative treatment

 

Type II

 

Displaced fracture of the head or neck 

- > 2mm and amenable to fixation

 

Motion may be mechanically limited with or without significant joint incongruity 

 

CT Radial Head FractureRadial Head ORIF

 

Management

- Kocher approach

- ORIF

- LCL repair / reconstruction

 

Type III

 

Severely comminuted fracture of the radial head and neck 

- not reconstructable 

- Titanium replacement

 

Radial Head Replacement

 

Ashwood et al JBJS Am 2004

- 16 patients titanium monoblock radial head

- 81% G/E at 2 years

 

Radial Neck Fracture

 

Morrey et al J Orthop Trauma

- concern regarding loss of rotation with plating

- prefer to ORIF with oblique screws or radial head replacement

 

3.  Dislocation with Coronoid Fracture

 

Elbow Dislocation Large Coronoid Fragment

 

The coronoid is the most important portion of ulno-humeral articulation

 

Reasons

- provides anterior buttress

- attachment of capsule and brachialis

- anterior band of the MCL attaches to it

 

Manage as per Regan and Morrey Classification

- ORIF / repair type I / II

 

Regan and Morrey Classification

 

Type I 

- stable as nothing attaches to tip 

- shear fracture, not avulsion fracture

 

Type II 

- 50% coronoid

- elbow usually unstable / ORIF or suture

 

Type III

- > 50%

- uncommon

- can be comminuted

- ORIF or suture

 

Elbow Dislocation Large Coronoid Fragment 2

 

Approach

 

Universal posterior approach

- single posterior skin incision

- elevate flaps laterally and medially as required

- lateral approach to repair ulna LCL

- medial approach to repair coronoid

 

Medial approach

- isolate and protect ulna nerve  

- elevation of ulna origin of flexor pronator group anterior to FCU

- important if fracture is medial

 

Fixation

 

1.  Screw / buttress plate

 

Coronoid Buttress Plate APCoronoid Buttress Plate Lateral

 

2.  Sutures through capsule / Lasso repair 

- tie over drill holes through olecranon / endobutton

 

3.  Reconstruct with radial head, iliac crest, or allograft

 

Note:  Acknowledged by world class names as being difficult

 

4.  Dislocation + Terrible Triad

 

Complex Elbow Dislocation APComplex Elbow Dislocation Lateral

 

Definition

- radial head fracture + coronoid fracture + MCL

 

Surgical Algorigthm

 

Universal Posterior Approach

 

1.  Type 2 radial head

- Kocher approach

- ORIF

- repair / reconstruct ulna LCL

- reassess stability

- if unstable, additional medial approach

- isolate and protect ulna nerve

- if type II / III coronoid elevate CFO and ORIF / suture

- repair / reconstruct MCL

- assess stability

- rarely may require external fixator

 

2.  Type 3 radial head

- Kocher approach

- excise radial head

- attempt ORIF / suture coronoid process through this gap

- unless large anteromedial fracture which is best treated with anteromedial buttress plate

- replace radial head

- repair / reconstruct LCL

- reassess stability

- may then need medial approach and MCL repair / reconstruction

- reassess stability

- may need hinged external fixator

 

5.  Dislocation with Olecranon Fracture +/- Coronoid Fracture +/- Radial Head Fracture

 

Elbow Dislocation Fracture Olecranon and Radial HeadElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repairElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repair

 

A.  Anterior / Trans Olecranon Fracture Dislocations

 

Less common, better outcomes because

- coronoid fragment usually larger / easier to ORIF

- collaterals often intact

- radial head often intact

 

Management

- universal posterior approach

- ORIF / suture coronoid through olecranon fracture

- TBW or plate for olecranon fracture

- can repair coronoid with lag screw from olecranon plate

- Kocher approach

- ORIF / replace radial head

- repair / reconstruct LCL

- reassess stability

- +/- repair reconstruct MCL

 

B.  Posterior Monteggia Fracture

 

Elbow Dislocation Posterior Monteggia

 

More common, worse outcome because

- LCL more likely to be ruptured as well

- coronoid more likely to be comminuted

- radial head fracture

 

Management

- ORIF coronoid through olecranon fracture

- ORIF olecranon (often plate as distal to centre of rotation of elbow)

- +/- ORIF /replace radial head

- +/- repair / reconstruct LCL

- +/- hinged fixator

 

6. Other

 

Dislocation with distal radius fracture

 

Dislocated Elbow Fracture wristDislocated Elbow Fractured Wrist

 

 

Distal Biceps Tendon Rupture

Epidemiology

 

Dominant arm of middle aged men

- between 40 and 60

 

Aetiology

 

Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load

 

Pathology

 

Degenerative changes seen on histology

 

Types

 

Complete

- retracted / rupture of lacertus fibrosis

- minimally retracted

 

Partial

- small - partial tears of some fibres

- large - near complete avulsion of biceps tendon from radial tuberosity

 

NHx

 

Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength

 

Examination

 

Distal Biceps Rupture

 

Acute onset pain / distal swelling / bruising

 

Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact

 

Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon

 

O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test

 

Biceps Tendon Hook Test

 

Weakness

- supination > flexion

 

Distal Biceps Rupture 1Distal Biceps Rupture 2Distal Biceps Rupture 3

 

X-ray

 

May see bony avulsion from radial tuberosity

 

MRI

 

Confirm diagnosis

 

A.  Complete tear / retracted

- relatively easy to diagnose

 

Distal Biceps Rupture MRI

 

B.  Partial tear

 

Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue oedema

 

MRI Biceps Partial TearBiceps Partial tear

 

Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears

 

Management

 

Non-operative

 

Indication for complete tears

 

Elderly patients who do not require full strength and endurance

 

Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

- i.e. labourer might have difficult with inserting screws

 

Operative

 

Indication

 

Young active patients with recent rupture 

- may be more difficult with chronic tears

 

Options

 

Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury

 

One incision

- single anterior incision

- use suture anchors / endobutton to fix to tuberosity through this incision

- theoretical higher risk PIN injury

- endobutton fixation 2 - 3 x higher strength than suture anchors

 

Operative Technique:  One incision technique with endobutton

 

Set up

- supine, arm board, tourniquet

 

Incision

- longitudinal medially / transverse across cubital fossa / longitudinal mobile wad

- S shaped

 

Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound

 

Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final

 

Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

- leave 2 mm space between endobutton and distal end of tendon

- allows space for dorsal cortex of radius

 

Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which

 

Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity

 

Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN

 

Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II

 

Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair

 

Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52

 

Results

 

Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength

 

Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side

 

John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients

 

Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques

 

Mazzocca et al Am J Sports Med 2007

- biomechanical study

- endobutton (440N) stronger than suture anchors (380N) or bone tunnel (300)

 

Lo et al Arthroscopy 2011

- 11 mm to PIN if aim directly across long axis of radius

- increases to 16 mm if aim 30 degrees to the ulna side

- aiming distally 45 degrees and radially decreased this to 2 mm

 

2 incision Boyd and Anderson Technique

 

Technique

 

Anterior Henry approach as before

 

Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius

 

Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator

 

Repair

- performed through bone tunnels

 

Results

 

Greewal et al JBJS Am 2012

- single incision (anchors) v double incision (drill holes)

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance

 

Partial Tears

 

Management Options

 

Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%

 

Surgical Treatment of a Partial Tear

 

Biceps ApproachBiceps Partial TearBiceps Partial Tear 2Biceps Partial Tear 3

 

Repair with suture anchors

 

Biceps Suture Anchor Repair

 

Chronic Tears

 

> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion

 

Typically run into problems > 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction

- secure to radial tuberosity with endobutton first

- then weave through distal biceps stump

- pulve taft weave through tendon

 

Hamstring autograft biceps reconstruction

 

Biceps reconstruction with tendoachilles allograftDistal biceps reconstruction with allograft

 

Complications

 

Infection

Rerupture

Injury LCNFA

Injury PIN

Loss of extension

- more common with chronic injuries

Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture

 

2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture

 

In the second group fixation can be very difficult

 

Anatomy

 

Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns

 

Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation

 

Elbow AP NormalElbow Normal AP 4 degrees valgus

 

CT scan

 

Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension

 

Muller's Classification

 

Type A: Extra-articular fracture

 

Distal Humerus Fracture

 

Type B: Uni-condylar fracture

- lateral /  medial

 

Elbow Medial Condyle FractureElbow Lateral Condyle Fracture

 

Type C: Bi-condylar fracture

 

Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture

 

Operative Management

 

Timing

 

Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO

 

Options

 

1.  ORIF

 

2.  Distal humeral replacement / osteoporotic and highly comminuted fractures

 

Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o

 

McKee et al JSES 2009

- RCT 42 patients > 65 years of age

- ORIF vTEA

- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA

 

Impression

- good treatment if unable to ORIF

- high level of skills required

- can replace distal humerus only if ligaments and proximal ulna preserved

- otherwise must replace ulna +/- linked prosthesis

 

3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function

 

Distal Humerus Non Operative

 

Approach

 

Extra-articular fracture

 

Distal Humerus Extraarticular ORIF

 

1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates

 

2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact

 

3.  Split triceps

- feather with osteotome off ulna medial and laterally

 

Intra-articular fracture

 

Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy

 

Technique for Intra-articular fracture

 

Distal Humerus ORIF APDistal Humerus ORIF Lateral

 

Position

- lateral decubitus with bolsters

- arm over bolster

- tourniquet

- may need to prep and drape iliac crest for bone graft

 

Elbow Lateral Decubitus

 

Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected

 

Chevron Olecranon Osteotomy

 

Chevron Osteotomy

 

Technique

- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

- complete with osteotome so can interdigitate fracture and not saw away segment of articular cartilage

- take fragment and retract proximally, taking triceps with it to expose distal humerus

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes

 

Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II

 

Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

- can get variants of posteriorlateral plate to fix coronal plane fracture of capitellum (AP screws in PL plate)

- fix with locking screws

- ensure not in olecranon or coronoid fossa  

 

Assess ROM

- no block to motion

- good stability

 

Check II

 

Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  

 

ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW

 

Post op 

 

POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)

 

Results

 

G/E 75%

 

Complications

 

ROM

- loss of 10 - 20o extension common

 

Humeral non union

 

Olecranon osteotomy non union

- 5%

- bone graft and plate

 

Ulna nerve palsy

- keep in mind the need to perform anterior transposition in original OT

- treat with neurolysis + transposition

 

Painful Hardware

- most common

- re-fracture risk if remove both plates

 

Adult Lateral Condyle Fracture

 

Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2

 

Definition

 

Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea

 

Management Options

 

These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate

 

Adult Medial Condyle Fracture

 

Elbow Medial Condyle Fracture

 

Anatomy

 

Medial epicondyle is common origin of several flexor muscles of hand and wrist

When medial epicondyle is fractured, flexor muscles pull fragment distally

 

Management

 

1.  Medial approach

- find and protect ulna nerve

- ORIF with screws

 

2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

- ensure at end no encroachment of  plate on nerve or might need anterior transposition

 

Transcondylar Fracture

 

Definition

 

Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone

 

Treatment

 

Non-displaced fractures are treated with splinting or percutaneous pinning

 

Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement

 

Capitellar Fracture

 

Uncommon fracture which is difficult to diagnose if fracture fragment is small

 

Elbow Capitellar FractureCapitellar Fracture CT SagittalCapitellar Fracture CT Axial

 

Type I

- Hans Steinthal fracture

- fracture of the capitellum in the coronal plane

- involves large part of the osseous portion of capitulum

- fracture hinges anteriorly between radial head and radial fossa producing a block to flexion

 

Management

 

If closed reduction is obtained, then reduction is usually stable with elbow flexion

 

Open reduction

- Kocher approach

- one or two headless compression screws

- front to back

- buried

 

Capitellar Fracture ORIF0001Capitellar Fracture ORIF0002

 

Type II

- Kocher Lorenz fracture               

- affects primarily articular cartilage and very little underlying bone

- these usually cause few subsequent joint problems

 

Management

- healing potential is minimal & excision is recommended

Epicondylitis

Lateral Epicondylitis / Tennis Elbow

Incidence

 

Lateral : Medial 9:1

 

Epidemiology

 

4th & 5th decades

- M = F

- 75% dominant arm 

 

50% of regular tennis players

- especially > 2 hrs / week

 

Aetiology

 

Insertion pathology / Enthesopathy

 

Over-extension of the elbow with supination / pronation

 

Anatomy

 

Lateral epicondyle

- anconeus from posterior face

- ECRB and EDC from anterior face (CEO)

- ECRL and BR from lateral supracondylar ridge

 

Differentiate ECRB from ECRL

- ECRB tendinous insertion onto lateral epicondyle

- ECRL still muscular at this point (arises more proximally)

 

LCL

- apex of lateral epicondyle

 

PIN

- radial nerve between brachialis and BR

- divides at level of radial head

- enters supinator at this level (radial tunnel)

 

DDx

 

1.  OCD capitellum / radial head

2.  Radial tunnel / supinator / PIN syndrome

3.  PLRI

4.  OA, RA

5.  Referred Pain / C6-7 radiculopathy

6.  Enthesopathy

7.  Annular ligament tears

 

Risk factors

 

Tennis

- poor technique

- poor grip

- hard court surfaces

- strings too taut

 

Occupational

- plumbers

- painters

 

Pathophysiology

 

Starts as micro-tear in ECRB 

 

Histology

 

Angiofibrotic hyperplasia

- marked fibroblast proliferation

- extensive vascular hyperplasia

- disorganised collagen production

- may go on to dystrophic calcification

 

Disruption of parallel orientation of collagen fibres 

- invasion of fibroblasts and vascular granulation type tissue

- without an acute or chronic inflammatory component

 

History

 

History of overuse

Pain lateral elbow

Backhand in tennis main problem

 

Examination

 

Localised Swelling

 

ROM

- few degrees loss of extension = CEO

- >15-20° loss is intra-articular pathology

 

Tender ECRB

- 5 mm distal and anterior to CEO

 

Test

- pain with resisted wrist dorsiflexion with elbow extended

 

Examine for Stability - PLRI

Examine Supination / Pronation - radiocapitellar OA

Examine C spine

 

DDx

 

Radial Tunnel Syndrome

- tenderness 3-4 cm distal to lateral epicondyle

- pain with resisted thumb / IF and supination

 

Xray

 

Usually normal

25% soft tissue calcification

 

Tennis Elbow CalcificationTennis Elbow Bone Spur

 

NCS 

 

Normal

 

MRI

 

Will demonstrate tears and oedema on T2

 

Elbow MRI Lateral Epicondylitis

 

Management

 

Non Operative

 

Timing

 

6-9 months

- successful ~ 75- 85%

 

Rest Phase

 

Complete rest lasting for 3-6/52

-  avoid precipitating factors

 

NSAIDs

- oral or topical

 

Brace

- wrist in extension

- cock up wrist splint

 

Forearm tennis band

- limit muscle expansion

- may create new force direction

 

HCLA injection

- find patient's maximum tenderness deep to fascia 

- repeat 2-3 times over 6-12 months

- peri not intra-tendinous

- must then rest the tendon for it to work long term

- risks of local skin depigmentation and CEO rupture

 

Conditioning Phase

 

Once pain settled

- Extensor origin stretching 

- Wrist extension exercises (1lb increments)

- eccentric muscle training

- ART (active release technique)

- Activity modification / change racquet and stroke

 

Tyler et al J Should Elbow Surg 2010

- RCT using eccentric muscle training

- significant improvement in outcome

 

Adjuctive Therapy

 

1.  Shock wave lithotripsy

 

Meta-analysis of RCT

- minimal effect comparted with placebo

 

2.  Autologous Blood / PRP Injections

 

Peerbooms et al Am J Sports Med 2010

- RCT autologous blood v corticosteroid

- superior outomes with plasma cell injections at one year

 

3.  Botox Injections

 

Improvements compared with placebo

Inferior to corticosterioid

 

Operative Management

 

Indication 

 

Failure of good non-operative management

- > 6 - 12/12

 

Options

- open debridement

- percutaneous tenotomy

- arthroscopic

- radiofrequency microtenotomy

 

Open debridement

 

3 cm incision 

- centred on CEO

- ECRB is deep and posterior to ECRL

- ECRL muscular at this point

 

Surgical dissection

- Detach ECRB

- Debride degenerative tissue

- Decorticate underlying CEO

- +/- reattach ECRB

 

Tennis Elbow ReleaseTennis Elbow Release 2

 

Tennis Elbow Release 3Tennis Elbow 4

 

Modifications

- Z lengthen

- denervate sensory nerves to epicondyle

- combine with decompression PIN

- cover with anconeus flap in chronic or recurrent cases

 

Post-op

- splint 10 days

- gentle ROM to 6/52

- then strengthening exercises

 

Arthroscopic Release

 

Arthroscopic Tennis Elbow Release 1Arthroscopic Tennis Elbow Release 2Arthroscopic Tennis Elbow Release 3

 

Complications

 

Instability

- inadvertant release LCL

 

Neuroma

- posterior cutaneous nerve forearm

- runs 1.5 cm anterior to lateral epicondyle on BR fascia

 

HO

- rare, but can be devastating

 

Results

 

Dunn et al Am J Sports Med 2008

- retrospective study of 92 elbows over 12 years

- open release

- 84% good to excellent results

 

Baker et al Am J Sports Med 2008

- 42 patients with arthroscopic resection followed up for 10 years average

- 87% patient satisfaction

 

Dunkow et al JBJS Br 2004

- RCT open v percutaneous tenotomy

- earlier return to work and faster recovery

 

Meknas et al Am J Sports Med 2008

- RCT of open release v microfrequency tenotomy

- no difference in pain relief

- better grip strength at 12 weeks

Medial Epicondylitis / Golfers Elbow

Incidence

 

10% of elbow tendonitis

 

Aetiology

 

Overuse injury

- poor swing in golf

- poor throwing technique

- overuse of topspin in tennis

- occupational (repetitive hammering / screwing)

 

Some patients also have lateral epicondylitis

 

Examination

 

Tenderness CFO

 

Stimulate pain

- flexion of WJ with fingers resisting

- resisted pronation 

- resisted ulna deviation

 

May have ulna nerve symptoms

 

Xray

 

Rule out OA / OCD elbow

 

DDx

 

MCL insufficiency

- must differentiate from MCL instability

- if release CFO in setting of MCL laxity will have frank instability post-op

 

Management

 

Non-Operative Management

 

As per tennis elbow

 

Operative Management

 

Surgical Release

 

Medial incision

- identify and protect ulna nerve

- release of CFO

- protection of MCL

- debridement of scar and bony prominence

- drill holes into epicondyle

- reattachment of CFO

- + / - Ulnar nerve decompression

 

Post op

- splint

- no resisted wrist flexion / pronation 6 - 8 weeks

- no sport for 4 - 6 months

 

Results

 

Segal 1992

- small series 

- 11 of 16 good results with operative release

 

Vangness JBJS Br 1991

- 35 operative cases

- felt the underlying pathology was a tear in the CFO

- incomplete healing

- treatment as described above

- 34/35 good or excellent results

- 1 patient could not return to sport

 

 

 

Forearm Fractures

Anatomy

 

Radial bow radius

- important for rotation

 

Interosseous membrane

- Z pattern

- proximal radius to distal ulna

 

Mechanism

 

Direct blow

- ulna / night stick

 

Ulna Fracture Night Stick

 

Indirect

 

Monteggia

- Proximal 1/3 ulna fracture with radial head dislocation

 

Elbow Monteggia FractureElbow Monteggia Fracture ORIF

 

Monteggia Variant

- proximal 1/3 ulna fracture with radial head / neck fracture

 

Monteggia Variant APMonteggia Variant Lateral

 

Galleazzi

- distal 1/3 radial fracture with DRUJ disruption

 

Galleazzi APGalleazzi LateralGalleazzi Xray APGalleazzi Xray Lateral

 

Associated Injuries

 

Ulna can be compound

Compartment Syndrome

 

Compound Ulna

 

X-ray

 

Joint above and below

 

Elbow

- always assess radial capitellar line on two views

 

DRUJ disruption

- widened space between R & U

- radial shortening > 5 mm

- ulna styloid fracture

 

Classification

 

Isolated single bone

 

Both bone

 

Fracture of one bone with ligament rupture

- Galleazzi, Monteggia

 

Fractures of bone bones with ligament rupture

 

Non operative Management

 

Indications

 

Ulna

- < 10o angulation

 

Ulna Fracture Undisplaced

 

Radius

- completely undisplaced

- maintenance radial bow

 

Operative Management

 

Options

 

Intramedullary fixation

- children (good remodelling potential)

- prophylaxis to prevent pathological fracture

 

Ulna Intramedullary Wire

 

External Fixation

- severe injury / compound

 

Plate fixation

 

Ulna Plating

 

Goals

 

Anatomical reduction with absolute stability

- length

- rotation

- radial bow (need to bend plate for long fractures)

 

Approach

 

Forearm Fractures Plate LateralForearm Fractures Plate AP

 

Ulna

- approach between ECU / FCU

 

Radius

 

Distal

- between FCR and radial artery

 

Proximally

- between BR and pronator teres

- supinate forearm

- elevate supinator from ulna to radial

 

Galleazzi

 

Incident DRUJ instability

- up to 50% if fracture radius < 7.5 cm to distal articular surface

- < 5% if > 7.5 cm

 

Galleazzi ORIF 1Galleazzi ORIF 2

 

Plate distal radius

- assess DRUJ stability

- if stable, early ROM

- unstable, splint in supination

- if still unstable, ensure that radius is anatomical

- may have to repair TFCC / ORIF ulnar styloid

- if still unstable, may rarely have to K wire ulna to radius

 

Galleazzi ORIF APGalleazzi ORIF Lateral

 

Complications

 

Nonunion

- 2%

- exclude infection

 

Radial Fracture Non Union CTUlna Non Union

 

Malunion

 

Problem

- > 10o angulation leads to loss of ROM

 

Management

- osteotomy

 

Radial Fracture Malunion Radial Fracture Malunion 2Radial Osteotomy Radial Osteotomy Lateral

 

Infection

 

Management

 

Initial

- excise non union 

- debridement

- ABx cement spacer + external fixator

- eliminate infection

 

Obtain union

- BG and plate

 

Compartment syndrome

- don't close fascia

- good haemostasis

 

Synostosis

 

Risk factors

- fractures at same level / Monteggia

- proximal fractures

- open fractures

- head injuries

- bone grafting

- ORIF through single incision

- delayed surgery > 2 weeks

 

Management

 

Excision

- usually posterior approach

- elevate ECU from ulna

- exposes synostosis and radius

- application of bone wax to bone after debridement

- +/- irradiation / indomethacin especially in head injured patients

- worst results with proximal synostosis

 

MCL Insufficiency

AetiologyTommy John Surgery

 

Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity

 

History

 

Initially

- lose velocity / accuracy

 

Develop medial pain

 

40% ulna nerve symptoms

 

Examination

 

Pain on palpation of anterior bundle MCL

 

CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion

 

Jobes test

 

Valgus stress with elbow flexed 25o to unlock olecranon

- forearm pronated to prevent false positives due to lateral side laxity

- problem is shoulder ER

 

Modification

- lie patient prone

- apply valgus stress

 

Elbow MCL Test ProneElbow MCL Test Prone 2

 

Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain

 

MIlkers Sign 1Milkers Sign 2

 

Anatomy

 

Elbow MCL Anatomy

 

X-rays

 

40% calcification MCL

 

Stress view

- > 3mm difference from opposite side

 

MRI

 

Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings

 

Management

 

Non Operative

 

RICE

NSAIDS

 

Physio      

- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction

 

Really amounts to 6/12 rest

- problem for professional athletes

 

Operative

 

Tommy John Surgery

 

Named after famous American baseball pitcher

- first to have this surgery

 

Options

 

1.  Repair

- not often able to be done

- perhaps in acute tear

 

2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described

 

UCL reconstruction

 

Tommy John Surgery

 

Numerus techniques described

 

Palmaris longus / gracilis graft

 

Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP

 

Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve

 

Figure of 8

- tension at 30o

- suture both limbs together to improve tension

 

Post-Op

 

Immobilise for 10/7

ROM brace for 4/52

 

No throwing for 6/12

No sport for 12/12

 

Results

 

Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months

 

Posterior Elbow Impingement

 

Symptoms

 

Cause posteromedial pain

- probably related to subtle UCL instability

 

May be protective

 

Examination

 

Pain posteromedially with full extension

 

CT

 

Identify posterior olecranon osteophytes

 

Management

 

Arthroscopic Resection

 

Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective

Myositis Ossificans

 

Elbow Myositis OssificansElbow Myositis Ossificans

 

DDx

 

Parosteal OS

- bone is not continuous with cortex in MO

 

Aetiology

 

3% incidence in elbow joint trauma to some degree

 

Head + elbow joint trauma > 90%

 

Pathogenesis

 

Ectopic bone may ossify ligaments and capsule

- does not respect anatomical boundaries

- can completely envelope ulna nerve

- may form radio-ulnar synostosis

 

Usually in brachialis

 

Xray

 

Elbow HO

 

CT

 

Show mature trabeculation

Define anatomical location

 

Elbow CT Posterior HOElbow CT HO Anterior

 

Surgery

 

Timing

 

Gartland 

- negative Alk Phos and negative bone scan do not rule out recurrence after excision

- recommends do not resect till about 18/12

- well defined trabeculae on x-ray

 

Excision must be coupled with prophylaxis

 

Prophylaxis

 

Indomethacin

- 25 mg tds for 2 - 6 weeks

 

Radiotherapy

- 700 Gray single dose post operatively

 

Prognosis

 

A poor neurological recovery and spasticity associated with recurrence

 

Approach 

 

Depends on site of ectopic bone

 

Options

- posterolateral

- anterolateral

- medial

 

Elbow HO Excision PreopElbow HO Excision Post op

 

Complications

 

Recurrence

 

Nerve injury

 

Beware post operative instability

 

Elbow Post HO Excision

 

 

Olecranon Fracture

Definition

 

Intra-articular proximal ulna fracture

 

Anatomy

 

Articulates with trochlea

- may have a central bare area

 

Triceps insertion

- via broad aponeurosis which blends with anconeus and CEO

 

Management

 

Non operative Management

 

Undisplaced fracture

- need to ensure triceps mechanism is intact

- Long arm POP 3/52 in 90o flexion

 

Operative Management

 

Indications

 

1.  Disruption of extensor mechanism

- any displaced fracture

2.  Articular incongruity

 

Options

 

TBW

Plate

Excision fragment / triceps advancement

 

TBW Technique

 

Elbow Olecranon FractureOlecranon Fracture AP TBWOlecranon TBW Lateral

 

Goal

- convert the tensile distraction force of triceps into a compressive force at the articular surface

 

Options

- bi-cortical K wires

- intra-medullary k wires

- intramedullary screw

 

Contraindication

- fracture distal to centre of rotation / midpoint of trochlea notch

- highly comminuted fractures

- oblique fractures

- best to use plate in these situations

 

Technique

- lateral decubitus over bolster

- curvilinear incision to avoid prominence of olecranon

- clean and washout haematoma

- reduction (extend elbow to defunction triceps / place bone forcep)

- 2 x IM k wires (no need to bite anterior cortex / risk nerve injury)

- drill hole in ulna, pass 20 gauge wire

- form figure of 8 wire about wires, can pass under triceps

- twist via 2 knots

- bury end of K wires under triceps

 

Screw / TBW

 

Beware bow of proximal ulna

- may cause medial shift

- avoid long screw

 

Plate

 

Olecranon Fracture Lateral

 

Indication

- fracture distal to centre of rotation

 

Main problem is hardware prominence

- precontoured low profile

- proximal hooks to grip triceps

- beware over compression articular surface in comminuted fractures

 

Olecranon Plate

 

Excision fragment / triceps advancement

 

Indications

- elderly

- osteoporotic

- < 50% articular surface

- non reconstructable

 

 

 

 

Osteoarthritis

Epidemiology

 

Relatively rare

 

Average age 50

 

Men 4:1 Women

 

Usually dominant arm

 

Aetiology

 

Primary

- associated with strenuous manual labour

 

Secondary

- trauma

- OCD

- synovial chondromatosis

- valgus extension overload / MCL insufficiency

 

Pathology

 

Begins radiocapitellar joint

 

Progresses to ulnohumeral joint

 

Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses

 

Clinically

 

Often have end range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge

 

X-ray

 

May have well preserved radiocapitellar and ulnohumeral joints

 

Osteophytes olecranon and coronoid

 

Elbow OA LateralElbow OA AP

 

CT

 

Useful in defining antomy pre operation / identification loose bodies

 

Elbow Arthritis CT

 

Elbow Loose Bodies CTElbow Loose Bodies CT 2

 

MRI

 

Useful in detecting early chondral damage

 

MRI Radiocapitellar OAMRI Ulna Trochlea OA

 

Arthroscopy

 

Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage

 

DDx

 

Inflammatory arthritis / RA

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion

 

Management

 

Non operative

 

Analgesia

HCLA

 

Operative

 

1.  Open procedures

 

A.  Open capsular releases

- for stiffness

- releases as required

 

See Elbow / Stiffness

 

B.  OK procedure

- removal of coronoid and olecranon osteophytes

 

See Elbow / Stiffness

 

2.  Arthroscopic Osteochondroplasty and Releases

 

Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection

 

Posterior joint

- remove loose bodies

- resect olecranon osteophytes

 

See Elbow / Arthroscopy

 

3.  Total elbow arthroplasty

 

Indications

- > 65

- sedentary

 

Results

 

? reduced long term survival compared to RA

 

Bjord-Tilde et al J Should Elbow Surg 2009

- Norwegian Joint Registry

- 469 RA revision rates 7% at 5 years and 15% at 10 years

- OA numbers small (24) with 5% revision rate at 5 years, 10 year not available

 

Posterolateral Rotatory Instability

Definition

 

Radius rotates externally in relation to the ulna

- posterior displacement of the radial head relative to the capitellum

- in flexion

 

Posterolateral rotatory Instability

 

Anatomy LCL

 

LCL Elbow

 

Pathology

 

1.  Laxity or tear of ulna LCL

- posterior dislocation / subluxation / perching

- most common cause

 

2.  Torn CEO

- dynamic restraint

 

3.  Depressed fracture of radial head / malunion coronoid fractures

- leading to loss of secondary restraint

 

Mechanism

 

Dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL

 

Aetiology

 

Trauma

- acute LCL tear after dislocation

 

Iatrogenic

- tennis elbow release

- Kocher approach

 

Ligamentous laxity

 

Long standing cubitus varus

 

History

 

Posterolateral elbow pain

 

Describe clunk on full extension

 

Patient may be able to demonstrate instability

 

Examination

 

Test combines external rotation / supination with valgus and axial loading

 

1.  O'Driscoll Pivot Shift Test

 

Best with patient anaesthetised

- can sublux joint

 

If patient awake, only get pain and apprehension

 

Patient supine

- examiner at head of bed

- GHJ full flexed with hand over head

- elbow resembles knee in this position

- forearm supinated

- elbow fully extended

 

Valgus stress with axial load & slowly flex joint

- at 40o the radial head is subluxed maximally posterolaterally

- radial head becomes prominent as it dislocates

- patient feels apprehension as the radial head subluxes

- past 40o flexion the radial head reduces

 

Positive

- prominent radial head (dislocates)

- pivot

- pain  (apprehension)

- maximum subluxation is at 40o flexion but with increased flexion reduces with snap

 

2.  Table Top Test

 

Push up on table with forearms in supination

- radial head subluxes, patient has apprehension

- relieved by thumb pressing on radial head

 

Table Top Test 1Table Top Test BeforeTable Top Test After

 

X-ray

 

 

Usually normal

- may be slight widening of radiohumeral joint

- radial head may appear slightly posterior

 

MRI

 

Difficult to distinguish lateral complex

 

Management

 

NHx

 

Does not improve with time

- usually requires surgery if very symptomatic

 

Options

 

1. Repair 

2. Imbricate

3. Reinforce/Reconstruct with PL graft

 

Reconstruction

 

Kocher approach between Anconeus & ECU

- drill holes x 2 base sublime tubercle

- drill holes x 2 at lateral epicondyle (isometric point)

- palmaris graft in figure of 8

- tighten with elbow at 30 - 40o of flexion

 

Post op

- hold flexed 2/52

- then allow ROM in hinged brace

 

Lateral Ligament Elbow Reconstruction

 

Results

 

O'Driscoll et al JBJS Br 2005

- retrospective review of 44 cases

- some direct repair, some autograft reconstruction

- 86% satisfaction

- better outcomes in reconstruction group

Radial Head & Neck Fractures

Radial Head Fracture

 

Mechanism

 

FOOSH

- axial load with a valgus force

 

Biomechanics

 

1.  Provides Valgus stability

- especially if MCL deficient

 

2.  Longitudinal stability

- aided by interosseous membrane

 

3.  Load Transfer

- 60% of load at elbow

- with radial head excision, load is transferred to ulno-humeral joint

- increase risk of OA

 

Hotchkiss modification of Mason Classification

 

Type I

 

Undisplaced fracture

- intra-articular displacement < 2mm

- no mechanical limit forearm rotation

- if in doubt, inject LA into radiocapitellar joint / soft spot

- ensure no mechanical block to rotation

 

Radial Head Mason 1Radial Head Fracture Mason 1

 

Type II

 

Displacement > 2mm

- motion mechanically limited

- reconstructable

 

Radial Head Fracture Type 2Radial Head Fracture Type 2 CTRadial Head Fracture Mason 2

 

Type III

 

Severely comminuted fracture of the radial head and neck

- not reconstructable

- requires excision for movement

 

Type IV

 

Associated with elbow dislocation

 

Complicated Radial Head Fracture

 

1.  Elbow Dislocation

 

2.  Essex Lopresti

 

Fracture Radial Head + Disruption DRUJ / Interosseous membrane

- dorsal dislocation of DRUJ

- ORIF / replacement radial head

- supinate DRUJ to reduce +/- TFCC repair +/- K wire

 

Surgical Options

 

1.  ORIF

 

Radial Head ORIF

 

Kocher approach

- between anconeus and ECU

- dissect muscles off capsule

- protect ulna collateral ligament under anterior edge of anconeus

- pronate forearm to protect PIN

- divide capsule in line with incision, create anterior and posterior flaps

 

Safe Zone for implants

- posterolateral portion of cartilage

- yellow and thinner

- non articulating

- 90o arc between radial styloid and lister's

 

ORIF 

- headless compression screws

 

Complications

 

AVN 

- soft tissue stripping

 

Non union 

- same reasons

- 10%

 

Results

 

Ring et al JBJS Am 2002

- results of ORIF Type III radial head

- overall 54% poor results

- good results with 2 or 3 fragments

- poor results with 4 results

  

2.  Excision

 

Indication

- elderly patient

 

Contra-indication

- MCL or interosseous membrane disrupted

 

Complications

- reduced strength

- proximal radial translation

- DRUJ instability and pain

- valgus instability elbow

- arthrosis (deceased SA, increased contact stresses)

 

3.  Replacement

 

Radial Head Replacement LateralRadial Head Replacement APRadial Head Replacement Monoblock

 

Options

 

1.  Silastic 

- less resistant to compressive forces

- can get synovitis

- good as temporary spacer

- can cut out later

 

2.  Titanium

- monoblock / modular / bipolar

 

Technique Modular Titanium Radial Head

 

Radial Head Replacement

 

Excise radial head

- insert trial broaches into neck

- small or large diameter, standard or long

- insert trial head size and thickness

- check xray

- ensure not overstuffed

- put through range

- prepare real implant on operating table

- have to insert head and neck as one piece

 

Radial Head Replacement Lysis APRadial Head Replacement Lysis Lateral

 

Results

 

Grewal JBJS Am 2006

- modular radial head

- 26 patients followed prosectively for 2 years

- no revisions

- mild OA in 19%

 

Burhart et al J Should Elbow Surg 2010

- bipolar radial head

- 17 patients followed up for between 6 and 10 years

- 2 dislocations, 8 had evidence capitellar OA

- no loosening

- 16/17 good or excellent results Mayo elbow scores

 

Complications

 

1.  Aseptic loosening

2.  Overstuffing

3.  Capitellar OA

4.  Malpositioning

 

Radial Head Poorly Positioned

 

Radial neck fracture

 

Radial Neck Fracture

 

Indications for surgery

- > 30o angulated

 

Approach

- Z incision annular ligament

- elevate supinator with arm pronated

 

Options

 

1. T plate in safe zone

- distal limit is bicipital tuberosity

- pre-contoured low profile plates

- may need to lag articular surface first

- check ROM intra-operatively

- plates often bulky and may limit ROM

 

Radial Neck Plate

 

2.  Fix with headless compression screws

- proximal to distal

- cross fracture site

 

Radial Neck Fracture ORIF Screws APRadial Neck Fracture ORIF Screws Lateral

 

3.  Retrograde Intramedullary Wire

 

4.  Radial Head Replacement

Rheumatoid Elbow

Elbow Rheumatoid ArthritisElbow Rheumatoid Arthritis 2

 

Epidemiology

 

50% rheumatoid patients have elbow pathology

- 80% also have shoulder pathology

- 90% hand and wrist

 

Always consider entire upper limb

 

Pathology

 

Synovitis

- swelling and pain

- may develop FFD due to holding in flexed position

 

Annular ligament may rupture

- anterior displacement of radial head

- due to pull of biceps

 

Collateral ligaments may rupture

- ML instability

 

Ulna nerve neuropathy

- synovitis

- rheumatoid nodule

 

Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction

 

Management

 

Non Operative

 

SMART / DMART / Immunological medications

 

HCLA

 

Splints

 

Turnbuckle braces

- night time

- for loss of extension

 

Operative

 

1.  Synovectomy +/- radial head excision

 

Indications

- minimal OA

- significant synovitis

- young patient

 

Radial head excision

- to improve rotation

 

Contra-indications

 

Elbow instability

- can worsen

- may develop progressive valgus

 

Options

 

1.  Open

 

A. Extended Kocher

- limited access to posterior olecranon

- limited access to medial side

 

B.  Universal Posterior approach

 

2.  Arthroscopic

 

Results

 

Maenpaa et al J Shoulder Elbow Surg 2003

- 103 synovectomies open synovectomies via Kocker approach

- 5 year survival (reoperation / TER) 77%

- best with early OA
- no improvement in ROM but good pain relief

 

2.  Arthrodesis / Resection arthroplasty

 

Salvage only

 

3.  Interposition arthroplasty

 

Results inferior to arthroplasty

 

4.  Arthroplasty

 

A.  Non constrained

 

Need ST stability and balancing

- there is an incidence of postoperative instability (7 - 19%)

- good ROM

- need stems to prevent loosening (high failure rate of resurfacing)

 

Ewald et al JBJS Am 1993

- 202 follow up for 6 years

- 1.5% revision 

 

B.  Constrained

 

Higher early rates of failure

- 22% 4 year revision rate

 

C.  Semi constrained

 

Morrey JBJS Am 1998

- Coonrad - Morrey prosthesis

- 97% minimally painful at 10 years

 

Coonrad-Morrey

- anterior flange on humeral prosthesis very important to survival

 

Latitude prosthesis

- unconstrained can be converted to constrained

 

Total Elbow Replacement RA LatitudeTotal Elbow Replacement RA Latitude

 

 

 

 

 

Stiffness

Functional range

 

30- 130o - Flexion / Extension

50o each - Pronation / Supination

 

Aetiology

 

Extrinsic

- skin / subcutaneous tissue

- capsule (anterior / posterior)

- collateral ligament contracture

- muscle contracture

- HO

 

Intrinsic

- articular deformity / malunion

- articular adhesions

- impinging osteophytes (olecranon / coranoid)

- impinging fibrosis (olecranon / coranoid)

- loose bodies

 

Mixed

 

History

 

Decreased flexion / extension

- ulno-humeral joint

 

Decreased pronation / supination

- radio-capitellar joint

 

Pain

- post-traumatic elbow stiffness is usually not painful

- indicates chondral damage

 

Examination

 

Active v passive ROM

 

Management

 

Non-operative

 

Options

 

Physio

- graduated active assisted stretching 

 

Dynamic hinged elbow splint 

- often poorly tolerated

 

Static progressive 

- turnbuckle splint

 

Operative Treatment

 

Options

 

MUA

- not recommended

- may worsen stiffness

- due to haematoma or articular damage

 

1.  Arthroscopic Release

2.  Open Release

3.  OK Procedure

4.  Interposition arthroplasty

5.  Total Elbow Arthroplasty

 

1.  Arthroscopy 

 

Used increasingly to treat stiffness

 

Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO

 

Technique

- remove scar tissue / loose bodies

- remove olecranon / coronoid osteophytes

- radial head resection

- resect bony malunions

- can perform modified O-K procedure

 

Case

 

Post elbow fracture malunion / posterior impingement / FFD 40o

 

Elbow Malunion LateralElbow Malunion MRI

 

Elbow Malunion ImpingementElbow Malunion Impingement

 

Elbow Malunion Partial DebridementElbow Malunion Post Debridement

 

Elbow Malunion PreopElbow Malunion Post Op

 

2.  Open Soft tissue releases 

 

Approach

 

Universal posterior approach

- arm over patient held by assistant

 

Lateral interval

- to distal humeral elevating BR and ECRL

- distally between ECRB and EDC

 

Medial interval

- find and protect ulna nerve

- between triceps and brachialis proximally

- detach pronator teres distally

 

Technique Morrey

 

A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus

 

B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule

 

C.  Excision of HO

 

D.  Removal of osteophytes

- coronoid / olecranon 

 

E.  Debridement of osteochondral flaps / loose bodies

 

F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable

 

G.  Radial head debridement / excision 

- especially if blocking supination / pronation

 

Results

 

Increases of 30 - 40o

 

3.  OK procedure

 

Elbow OK Procedure APElbow OK Procedure Lateral

 

Definition

 

Outerbridge - Kashiwagi procedure

- debridement athroplasty

 

Technique

 

Posterior approach 

- triceps split

 

Excision of posterior capsule

 

Excision of tip of olecranon

 

Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- use burr

- need to minimise bone dust

 

Debridement of coranoid and radial head

 

Removal of loose bodies

 

Results 

 

4.  Interposition Arthroplasty

 

Indication

- stiff elbow joint

- damage to >50% of ulno-humeral articular surface

- failure to achieve good range of motion following soft tissue release

 

Technique

 

Kocher Approach

 

Detach lateral ligament from humerus

 

Refashion ulno-humeral surface

- may be necessary in fracture or extensive malunion 

- create congruent surfaces for flexion / extension

 

Strip of fascia lata 

- fashioned and attached to anterior humerus

- fascia passed around end of humerus to cloth front and back

- then doubled on itself and attached to anterior ulna

- articular surface is fascia on fascia

 

Lateral ligament is then reattached

 

+/- hinged external fixation with distraction

 

5.  Total elbow replacement (arthroplasty)

 

Results

- 70% satisfaction

- less successful than RA

- some improvement in range (20o)

 

 

 

Hand

Compartment Syndromes

Upper limb fasciotomyForearm Fasciotomy Closure

 

1.  Antebrachial Compartment Syndrome

 

Aetiology

 

Supracondylar fracture of humerus

Both bone forearm fractures

 

Examination

 

Tense compartments

Pain +++

Passive extension of the digits or wrist increases pain

Paresthesias in median nerve distribution

 

Forearm Fasciotomy 

 

Decompression extending from elbow to wrist

 

Compartments (3)

- mobile wad

- volar

- dorsal

 

Incision

- medial arm

- across elbow

- continue as Henry approach into forearm

- can continue into palm as CTD incision

 

Release

- lacertus fibrosus  (releases median nerve at elbow)

- fascia of forearm (releases superficial volar)

- deep fascial compartments (FCU / FDP / FPL)

- mobile wad

 

Remeasure dorsal compartment

- often decompression of volar compartment will reduce dorsal pressures

 

Consequences

 

Volkmann's ischemic contracture

- result of delayed diagnosis

- severe muscle fibrosis & neuropathy 

- clawing of fingers

 

Muscles most commonly affected

- FDP

- FPL

 

Transfers

- BR to FPL

- ECRL to FDP

 

Compartment Syndrome of Hand

 

Aetiology

 

Iatrogenic injuries

- arterial line or infiltration of IV medications

Crushing trauma

IV drug abuse

High pressure injections

- i.e. paint guns

 

Clinically

 

Hand compartment syndromes lack abnormalities in sensory nerves

- no nerves are found within compartment

- non specific aching of the hand

 

Increased pain, loss of digital motion, continued swelling 

- tight swollen hand in a intrinsic minus position

- MP extension and PIP flexion

- intrinsic tightness (increased PIPJ motion with MCPJ flexion v extension)

 

Pressure measurement 

 

Should have a lower threshold than in leg compartments 

- pressures greater than 15-20 mmHg is a relative indication for release

 

Compartments

 

10 separate osteofascial compartments 

- dorsal interossei (4) 

- palmar interossei (3) 

- adductor pollicis (1)

- thenar and hypothenar  (2)

 

Decompression

 

CTD

- release thenar / hypothenar / adductor pollicis

- 2 x dorsal incisions over MC 2 and 4

 

 

Dupuytren's Disease

Background

Definition Dupuytrens

 

Palmar Fibromatosis 

 

Aetiology

 

AD with variable penetration

 

Pathogenesis

 

Murrell's Theory of Pathogenesis

 

1. Microvascular ischaemia

 

2. Leads to conversion of 

- ATP to Hypoxanthine

- Endothelial Xanthine Hydrogenase to Xanthine Oxidase

 

3. Xanthine Oxidase converts Hypoxanthine to Uric Acid

- gives off OH-

 

4 OH- releases Free Radicals 

- stimulate fibroblast proliferation & increased Type III Collagen

 

5  Fibroblasts strangle microvessels

- Vicious Cycle  

 

Luck's three stages of Dupuytren's contracture 

 

1st stage (proliferative) stage 

- increased cellularity

- number of large myofibroblasts

 

2nd (involutional) stage 

- dense myofibroblast network aligned to long axis of collagen bundles

- the ratio of Type III collagen to Type I collagen is inc

 

3rd (residual) stage 

- myofibroblasts disappear 

- fibrocytes are dominant cell type

- dense collagen cord remains

 

Myofibroblasts 

 

Cell of origin for the nodular myofibroblast is unknown 

- fibroblast / smooth muscle cell / pericyte

- Contractile cell

- nodules composed of myofibroblasts 

- No myofibroblasts in cords

 

Dupuytren's diathesis 

 

Aggressive early-onset form of the disease which involves the multiple areas

- usually have family history

- disease recurs rapidly following treatment

 

Feet (Ledderhose, 1897)

Penis (Peyronie) 

Garrod knuckle pads on dorsum PIPJs

 

Associations

 

Chronic alcoholism 

- ? metabolic effect on fat and prostaglandin metabolism

 

Diabetes mellitus 

- may be related to the diabetic microangiopathy

 

Epilepsy 

- likely effect of antiepileptic drugs on collagen metabolism

 

Smoking

 

Chronic pulmonary disease

 

Occupational hand trauma 

- controversial 

- probably only aggravation due to traumatizing an early nodule

 

Epidemiology

 

Age 50-70

Male 7:1

 

Caucasians

- especially celtics / vikings heritage

- rare in blacks & asians

 

Anatomy

 

A.  Involved anatomy

 

1.  Pre-tendinous Bands

- part of the palmar aponeurosis in palm

- common site of disease

- palpable nodule is pathognomonic of Dupuytren's

 

2.  Spiral Band

- continuation of pre-tendinous band into finger

- spirals deep to NV bundle then becomes superficial to bundle

 

3.  Natatory Ligament

- pass between the web spaces

- frequently diseased and prevents abduction

 

4.  Lateral Digital Sheet

- condensation of superficial fascia on either side of the finger

- receives fibres from the natatory ligament, spiral band, Grayson's and Cleland's ligaments

 

5.  Grayson's Ligaments

- hold skin during flexion and extension

- pass from fibrous tendon sheath to the lateral digital sheet

- volar to the NV bundle

- almost always involved in Dupuytren's

 

B.  Not involved anatomy

 

Skoog's fibres 

- transverse palmar fibres 

- run from flexor sheath to flexor sheath at the level of the A1 pulley

- the nerve is always deep to the fibres

- part of palmar aponeurosis

- deep to pre-tendinous band

- don't become diseased

 

Cleland's Ligaments

- hold skin during flexion and extension

- firm fascial structures 

- pass from the side of the phalanges to the skin

- dorsal to the neurovascular bundle

- involved in Dupuytren's only through mingling with the lateral digital sheet

 

MEM: Dave Christie Goes Volar

(Dorsal Cleland's, Grayson's Volar)

 

Site

 

LF / RF most commonly affected

MF / IF are sometimes affected

1st web sometimes affected

 

Pathology

 

5 Major Pathological cords

 

1.  Pretendinous cord

 

In palm / other 4 in finger

- diseased pretendinous band

- causes MCPJ deformity

 

2.  Central cord 

 

Diseased central fibrofatty tissue

- large nodule often present in cord just proximal to PIPJ

- causes PIPJ deformity

 

3.  Spiral cord 

 

Pathological spiral band

- usually connects to the P2 (bone and tendon sheath)

- displaces neurovascular bundle volarly

 

Difficult to predict presence

- associated with more severe contractures

 

4. Lateral Cord 

 

Diseased lateral digital sheath

- intimately adherent to skin (sharp dissection required)

- contributes to DIPJ +/- PIPJ

 

5. Natatory Cord 

 

Diseased Natatory ligament

- causes web contracture

 

3 Minor Cords

 

1.  Retrovascular Cord 

 

Involves longitudinal fibers dorsal to the bundle

- commonly seen in combination with other cords

- causes DIPJ extension with lateral cord

 

2.  Abductor Digiti Minimi Cord 

 

Cord arises from abductor digiti minimi

- from MT junction 

- to ulnar side of the base of P2

- commonly adheres to the lateral skin

 

3.  Intercommissural Cords / 1st Web 

 

Pathological changes in 

- pre-tendinous band (radial longitudinal fiber)

- superficial transverse fibers of the palm (proximal transverse commissural ligament)

- the first web natatory ligaments (Grapow's ligament)

 

Contractures

 

1.  PIPJ Contracture 

 

4 components

- Central cord 

- Spiral cord 

- Lateral cord 

- Retrovascular cord

 

Correction sequence

- resection pathological cords

- capsulotomy, release check rein ligaments

- release of accessory collateral ligaments performed

- release of volar plate 

 

2.  MCPJ Contracture

 

Always correctable by removal of central band

- Flexion deformity does not lead to collateral shortening 

 

3.  DIPJ Hyperextension

Occurs in advanced disease

- contracture of retro-vascular + lateral cord

 

History

 

Usually mildly painful nodules to begin

- palm of RF and LF rays

- very short lived

 

Severe night pain

- suspect fibrosarcoma

 

Progressive contracture of MCP, then PIPJ

- nodule over PIPJ warning of impending PIPJ contracture

 

Difficulty putting hands in pockets

- difficult gripping

- poke themselves in the eye

 

Diasthesis

- foot, penis

 

Examination

 

Nodules / dimples / pits

- palm, fingers

 

Contractures

- MCPJ

- PIPJ

- DIPJ extension

- web space contractures / natatory cords

 

PIPJ Contracture

- Examine PIPJ with MCPJ flexed

- eliminate effect of cord

- establish if any joint contracture

 

Diasthesis

- feet, Garrod's pads

 

Hueston Table Top Test

- Royal Melbourne hospital

- palm down on table

- positive if can slide pen under

- MCPJ contracture 30-40o

 

Surgery

Indications 

 

1. Significant functional impairment

 

2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30o

- may need to release  check rein ligaments / accessory collateral ligaments

 

3. MCPJ contracture >30o

 

4. Trigger fingers

- must do limited fasciectomy 

- otherwise may get exacerbation

 

5. CTS 

- treat dupuytren's 1st then carpal tunnel if doesn't settle

 

Contraindications

 

Advanced RA

Trophic changes due to vascular insufficiency

Unfit for GA

 

Risk for Recurrence

 

Diathesis

- Garrod's pads highest risk

- foot and penis involvement

Family History

Bilateral / Radial and ulna involvement / multiple digits

Males

Young patients and patients > 75

 

Options

 

Fasciotomy

Partial Fasciectomy

Complete Fasciectomy

Dermatofasciectomy and STSG

Amputation

 

Fasciotomy

 

Division of fascial cord

- Temporary method to relieve a severe MCPJ contracture

- not definitive therapy

- not in digits because high risk of neurovascular injury

- useful in elderly patients 

- results are better with dense mature cords 

 

Partial Fasciectomy

 

Dupuytrens surgery

 

Most common procedure

 

Recurrence rates of 50%

- need for repeat surgical procedure is only 15%

 

Technique

 

Longitudinal incision with Z plasty at end of case

- probably better with severe contracture as allows skin closure

- easier to protect NV bundles

- z at 60o

 

Careful flap elevation

- easy to button hole through skin

 

Dissection of NV bundles

- under then over spiral bands

 

Resection of diseased tissue

 

PIPJ  contracture > 30o

- MUA

- released check rein / accessory collateral / volar plate /  capsulotomy / flexor sheath

- note that a extended finger which does not flex is more debilitating than a FFD

 

Skin gaps

- due to large contractures

- FTSG

- McCash open technique (secondary healing)

 

Closure

- let down tourniquet for haemostasis

- consider drain

- check finger vascularity

 

Post-op

 

POP backslab in POSI

Wound check at 7 days

ROS 2 weeks

Night splint in extension for 3/12

 

Complete Fasciectomy 

 

Abandoned due high complication rate

- does not completely prevent recurrence of the disease

 

Dermatofasciectomy & FTSG

 

Indications

- recurrent disease

- young with diathesis / aggressive disease

- Recurrence under grafts very rare (Hueston)

- the FTSG as a fire break

 

Amputation

 

Rarely necessary

- may be indicated if severe PIPJ flexion 

- skin from involved finger may be used to cover palmar skin defect

- finger is filleted & skin folded into palm as pedicle with neurovascular bundles

 

Adjunctive Procedures

 

Trigger Fingers 

 

Excise diseased fascia with release of the A1 pulley

 

Pulley release without local diseased fascial excision

- may instigate a rapid progression of the Dupuytren's disease

 

Carpal Tunnel Syndrome 

 

Prophylactic CTD at time of fasciectomy is unwise

- accelerated scar formation may cause poor result

 

Partial Fasciectomy with CTD at later date

 

Complications 

 

Haematoma

- can be a problem for the skin

- lead to necrosis

 

Vascular Impairment/ Flap Necrosis

- finger white at end of procedure

- often due to vessel stretched after significant release

- bend fingers, leave tourniquet down

- papaverine on vessels as antispasmodic

- warm hand

- inspect vessels for damage

- wait

 

Nerve Injury

 

Reflex sympathetic dystrophy 

 

Finger Fractures

Incidence

 

1 / 1000 per year female

1.5 / 1000 per year male

 

Phalangeal fractures

- represent more than half of all hand fractures

 

Goals of Treatment

 

Restore normal function of the finger

 

1.  Restoration of bony anatomy

 

2.  Early motion

- inherent fracture stability

- splinting

- adequate internal fixation

- dynamic external fixation

 

Examination

 

Obvious swelling / bruising / deformity

 

Compound injuries

 

Rotational alignment

1.  With active flexion, all fingers point towards scaphoid tuberosity

2.  Evidence digital overlap (see below)

3.  Plane of nail beds all in same plane

- LF often slightly different rotation

 

Finger MalrotationFinger rotation normal

 

Tendon avulsion

 

X-rays

 

3 planes centred on MCPJ  middle finger

- AP

- lateral

- oblique

 

Care to look for subtle evidence joint subluxation

 

Principles Closed Treatment

 

POSI (Position of Safe Immobilisation)

- 20o wrist extension

- flexion of MCPJ to 60 - 70o

- IP joints in extension

- thumb in abduction

 

Acceptable alignment

 

Pun etal JBJS Am 1989

- 10o angulation in both planes

- no rotation

- 50% overlay

 

Surgical approaches

 

A.  Midaxial

- dorsal to NV bundle

- make dots on flexion creases with finger flexed

- this marks incision

- approach P1 by excision of one sagittal band

- less tendon disruption

- more difficult visualisation / access

 

B.  Midlateral

- volar to NV bundle

 

C.  Dorsal approach

- direct doral incision

- divide extensor hood over P1

- between lateral bands P2

- repair extensor mechanism at end

- risks scarring down of extensor tendon to implant

 

Types of injuries

 

1.  Extra-articular fractures

 

A.  Distal phalanx tuft fractures

B.  Shaft fractures of the distal, middle and proximal phalanges

 

2.  Joint injuries

 

DIPJ   

- dislocations

- mallet

- Pilon fractures

- Flexor tendon avulsion           

 

PIPJ    

- dorsal dislocations

- dorsal fracture dislocations

- volar dislocations

- Pilon fractures

- Condylar fractures

 

MCPJ dislocations

 

Tuft fractures

 

Most common hand injury

- usually crush mechanism

 

Management

- trephination of subungal haematoma (relieves pain)

- repair nail bed disruption

- irrigation and washout of open injuries

 

Distal phalangeal shaft fractures

 

Distal Phalanx Fracture 1Distal Phalanx Fracture 2

 

Non displaced fractures

– splint DIPJ for 2-3 weeks

 

Displaced

- higher energy fractures

- washout open wounds

- repair nail bed

- bony reduction with percutaneous K wire

- distal phalanx just under nail bed

 

Shaft fractures middle / proximal phalanges

 

Undisplaced

- usually stable

- buddy strap 3-4 weeks

 

Finger Fracture Undisplaced

 

Displaced

 

Finger Phalangeal Shaft FractureProximal Phalanx Shaft Fracture

 

Unstable fractures

- oblique, spiral, comminuted fractures

 

Transverse fractures P1 / characteristic deformity

- insertion of intrinsics at base PP flex fragment

- insertion of central slip to MP extend fragment

 

Finger Phalangeal Shaft Fracture Lateral

 

Fractures of P2 distal to insertion FDS / characteristic deformity

- FDS will flex fragment

- extensor tendon will extend fragment

 

Closed reduction

- relaxation of intrinsics

- axial traction

- reduction of deformity / POSI

 

ORIF

 

A.  Transverse fractures

- cross K wire

- Lister’s intra-osseous wire fixation

- plating

 

Hand Phalange Circular WireFinger Cross K Wires

 

B.  Long oblique / spiral fractures

 

Definition

- fracture must be at lease 2 x diameter bone

- can treat with 2 x lag screws

- one perpedicular to fracture to lag

- one perpendicular to shaft to resist shear

 

Options

- percutaneous K wires / screw fixation / plating

 

FInger Lag Screws

 

DIPJ Dislocations

 

Dorsal

- most common

- closed reduction with dorsal traction

- failed closed reduction – volar plate, FDP

- 60% injuries open

- splint joint in flexion 2- 3/52 weeks

- ROM at 1/52

 

Volar

- rare

- failed closed reduction – extensor tendon

- DIPJ extension splint 6-8/52

 

Mallet fractures

 

Mallet Finger

 

Mechanism

- axial load

- extensor tendon attached to bony fragment

 

Closed treatment

- mallet splint (Stack)

- expect 10o extensor lag with mild loss ROM

- good results with non – op management

 

ORIF

 

Bony Mallet Thumb

 

Indication

- volar subluxation of distal phalanx

- fragment > 50% joint surface

- chronic > 12 weeks old

 

Open treatment

- high incidence of complications

- percutaneous K wire recommended

 

Technique

1.  Reduce and axial K wire

2.  Dorsal blocking K wire / axial K wire

 

Wehbe and Schneider JBJS Am 1984

- 21 patients with intra-articular fractures

- 15 treated non operatively

- 6 treated operatively

- nil improvement in outcome

- worsened surgical morbidity

 

Pilon fractures base distal phalanx

 

Impaction injuries

 

Management

- ORIF very difficult

- all attempts at closed reduction +/- percutaneous pinning should be made

- fallback of arthrodesis / arthroplasty

 

FDP avulsions

 

Leddy and Packer classification

I   Vinculae are ruptured, tendon retracts to palm

II  Vinculae intact, tendon remains at PIPJ

III Large bony fragment, ensnared beyond A4 pulley

 

Type 1

- must be operated within 10 days to avoid contractures

- otherwise 2 stage reconstruction

 

Type 2 / 3

- can operate within 6 weeks

- ORIF large fragments

 

Condylar fractures of head of P1 / P2

 

Mechanism

- torsional and valgus impaction

 

London classification

Type 1  Unicondylar, undisplaced

Type 2  Unicondylar, displaced

Type 3  Bicondylar

 

Displaced unicondylar

- percutaneous K wire

- ORIF with screw

 

Finger Unicondylar Displaced FractureFinger Unicondylar Fracture ORIF APFinger Unicondylar Fracture ORIF Lateral

 

Open reduction

- P1 – between central slip and lateral band

- P2 – lateral to terminal extensor tendon

- must preserve collateral ligament which supplies blood

 

Type III bicondylar fractures

- difficult fractures

- 90 degree condylar plate

- lag screw and plate

- high risk of joint stiffness

 

PIPJ Dislocations

 

Types

- Dorsal

- Lateral

- Volar

 

Stabilisers

 

Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP

 

Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate

 

Volar plate

- thick distally

- thin proximally, allowing collapse during flexion

 

Dorsal dislocations PIPJ

 

Most common joint injury of the hand

- hinge joint permitting 110o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture

 

Mechanism

- hyperextension

- axial loading of the flexed fingertip

 

Stability

- dependant on integrity of the collateral ligaments

- if fragment is > 40 – 50%, the attachment of the true collateral ligament is lost

- unstable

 

Eaton Classification

 

I Simple hyperextension

- buddy strap, early ROM

 

II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10o further than instability

- each week extend further by 10o

- early aggressive ROM program

 

Dorsal Dislocation Simple

 

IIIA  fracture < 40% volar articular surface

- closed treatment with extension block

 

Finger Dorsal Dislocation Extension Blocking Splint

 

IIIB fracture > 40% + Pilon fractures

- inherently unstable

- extension blocking requires extreme flexion for stability, so risk of flexion contracture is high

- aim for congruent articular surface and early ROM

 

PIPJ Dislocation and Large Bony Fragment

 

IIIB Treatment Options

 

1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty

 

Dorsal Blocking K wire

 

Technique

- flexion P2

- dorsal entry into P1

- 40o flexion

- early removal at 3/52

- Improvement compared to extension blocking

 

Suzuki / Slade Dynamic Distraction external fixator

 

Concept

- closed reduction through ligamentotaxis

- early motion of PIPJ

 

Technique

- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

- third K wire mid-diaphysis P2,  prevents dorsal translation of MP

 

Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation

 

Hotchkiss designed PIP compass hinge

 

Technique

- K wire to centre head of P1 to set centre rotation

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked

 

Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks

 

Volar plate arthroplasty / Volar plate advancement

 

Technique

- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52

 

Finger Volar Plate Arthroplasty

 

Volar PIPJ dislocations

 

Finger Volar DislocationFinger Post Volar Dislocation

 

A.  Straight volar dislocation

 

Assessment of central slip post reduction critical

- if can active extend to within 30o, splint extended

- if nil active, surgical repair to prevent boutonniere

 

B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation

 

Lateral PIPJ dislocations

 

Rupture of one collateral ligament and volar plate

- may be bony avulsion

 

Management

- reduce and hold in extension 2/52, then protected ROM

- can perform primary repair or reconstruct

 

MCPJ Dislocation

 

Simple

- volar plate not interposed

- MCPJ 90o hyper-extended

- reduce via wrist flexion and volar translation of PP

- avoid hyperextension and axial distraction which may convert this injury to a complex dislocation

- extension blocking splint 3-4 weeks

 

Complex

- volar plate / lumbrical tendon / flexor tendons interposed

- joint space widened

- requires open reduction, dorsal or volar

- volar more direct but risk NV bundles

- protected motion post operatively

 

MCPJ Destruction

 

Cause

- infection

- trauma

 

Options

- joint replacement

- fusion

 

MCPJ DestructionMCPJ Fusion APMCPJ Fusion Lateral

 

MCPJ Replacement

 

 

Finger Soft Tissue Injuries

Detipping Injury

 

Definition

 

Distal to insertion of flexor and extensor tendons

 

Anatomy

 

Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum of skin

 

Nail complex

 

1.  Nail Plate

 

2.  Nail Bed

- adherent to thin periosteum of P3

 

A.  Proximal germinal matrix

- proximal part

- limit is semilunar lunula

- produces 90% thickness of nail plate

 

B.  Sterile matrix

- adherent to nail plate

- contributes little to thickness

 

3.  Paronychium

- surrounding skin on dorsum of fingertip

 

4.  Eponychium 

- covers nail plate proximally

 

5.  Hyponychium

- thick skin below distal edge of nail

 

Classification

 

A Oblique facing up

B Transverse

C Oblique facing down

D Oblique facing laterally

 

Tissue involved

- Pulp only

- Nail bed

- Bone

 

Goals

 

1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent Neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work

 

Management Pulp Loss

 

Pulp loss Finger

 

Options

 

1.  Primary healing

- best option

 

2.  Secondary healing

- < 1 cm2 area to cover

- 90% 5 year satisfaction

 

3.  Skin grafting

- 50% 5 year satisfaction

- most are painful

 

4.  Flaps

 

Local flaps / VY flaps

- Atasoy single volar

- Kutlers lateral flaps

 

Regional Flaps

- Cross-finger

- Thenar flap

 

4.  Formalisation

 

If bone on view and patient doesn't want flap

- take bone to level distal to extensor / flexor tendons

- remove nail bed in full (bilateral eponychial incisions)

 

Bone on View

 

Options

 

1.  Shorten and cover

2.  Preserve length and flap

3.  Secondary intention

- rarely a good option except in children

 

Soft tissue defects Finger

 

Local Flaps

 

1.  Atasoy  VY flap

 

Advantages

- local

 

Disadvantages

- often tender and sensitive long term

- can advance only 1 cm

- suitable for defects < 1 cm

 

Technique

- nibble bone back

- incise skin in V

- must release all fibrous septa form distal phalanx

- attempt to leave small vessels

- check is bleeding

- if avascular is usually because have not released all fibrous septa

- leaves too much tension on vessels

 

2.  Kutler's bilateral VY flap

 

Similar concept

- on both sides of digit

 

3.  Modified Kleinert flap

 

Lateral VY flap

- based on digital pedicle

- more volar VY flap than Kutler's

 

Regional Flaps

 

de-puplped finger injury

 

Disadvantages

- 2 stage procedure 

- Often result in finger stiffness

- Contra-indicated if diabetes / vascular disorders

- age relative contra-indication > 40 years

 

1.  Cross finger flap

 

Rectangle of donor skin from dorsum of P2

- Hinge is mid-axial line

- Must preserve paratenon over extensor tendon

 

Full-thickness skin graft to donor site from forearm

- transversely across bicipital groove

- must remove all fat from FT graft

 

Graft sutured 75% onto dorsum of donor finger

- flap crossed onto distal finger pulp

 

Divide flap under GA 3 weeks later

 

Results

- Obtain 10mm 2 point discrimination of flap

 

2.  Thenar flap

 

Indications

- source of good quality skin

- very similar to finger pulp

- 2 cm defect

- IF / MF / RF

- often difficult to oppose LF

 

Most important point is site of flap

- Position it high and parallel to MP crease

- If low or palmar can get debilitating donor site tenderness

 

Make skin 1.5 x defect size to reconstruct pulp

- donor site closed primarily or FTG

 

3.  Abdominal Flap

 

Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound

 

4.  Formalisation

 

 

B.  Soft Tissue Defects Thumb

 

Options

 

1.  Moberg advancement Flap

 

Indications

- only for thumb

- Cover 2cm defect

 

Technique

- mid-axial incisions from injury site to MPJ

- entire volar skin flap with both NV bundles

- flex IPJ, suture

- can do VY at base, or transverse incision and FTG at base

 

2.  Cross Finger Flap from Index Finger

 

3.  Littler Neurovascular Island flap

 

Ulna side of ring or little finger

- take on just one side

- significant secondary defect

- put a skin graft into secondary defect

- rarely first choice

 

3.  First dorsal Metacarpal Artery Flap

 

Technique

- skin over dorsum of P1 of IF

- 4-sided cut and mobilise on pedicle

- With art vein and nerve

- subcutaneous tunnel

 

4.  Free tissue transfer of great toe pulp

 

5.  Abdominal Flap

 

 

 

Gamekeeper's Thumb

Definition

 

Injury to ulnar collateral ligament of thumb MCPJ

 

Aetiology

 

Initial description

- chronic laxity of British gamekeeper's thumb's 

- no specific trauma

- secondary to breaking pheasant's neck

 

Acute trauma

- snow ski

- ball games

 

Valgus / forced abduction

 

Anatomy

 

UCL

- origin medial condyle metacarpal

- passes obliquely volarly 

- inserts on volar 1/3 of P1 and volar plate

 

Adductor aponeurosis 

- superficial to UCL

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid

 

Examination

 

Painful, swollen MCPJ

 

Tenderness along UCL

 

Abduction Stress Test

- in full extension and 30° 

- loss of end point or 30o > other side

- indicates complete rupture

 

X-ray

 

3 types Bony avulsion

 

1. Small fragment pulled away from P1

 

Thumb Bony Gamekeepers

 

2. Large intra-articular fracture involving >1/4 articular surface

 

3. S-H III in paediatric population

 

MRI

 

Look for stenar lesion

- when distal end of UCL

- flipped superficially over adductor aponeurosis

- will not be able to heal

 

A.  Undisplaced

 

MRI UCL Proximal Undisplaced InjuryTorn UCL Minimally Displaced MRI

 

B.  Displaced UCL

 

Management

 

Non operative

 

Indications

- partial tear

- undisplaced complete tear

- undisplaced bony fragment

 

Management

 

6/52 thumb spica

 

Operative

 

Indications for surgery

- complete tear with stener lesion

- large or small displaced bony fragment

- SH III in paediatrics

- chronic injury

 

Displaced Complete tear / Stener Lesion

 

Incidence

- 18 - 43%

 

Types

 

1.   Interposition of the adductor aponeurosis

- between a completely avulsed proximal ulnar collateral ligament injury

- and the proximal phalanx ligament insertion site

 

2.  Interposition between two ends of a mid-substance ligament tear

 

Diagnosis

 

Difficult clinically

- may be able to palpate displaced UCL

 

MRI

 

Technique

 

Dorsal incision along ulna border MCPJ

- Divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- Identify and repair UCL

 

Fixation

- direct suture if able to

- bony anchors

- through drill holes and over lateral button

- cerclage wire

 

Post op

- 6/52 thumb spica

 

Gamekeepers Thumb Repair

 

Bony Avulsion

 

ORIF Indications

1.   > 25% articular surface

2.   Small avulsion fracture displaced > 5mm

3.   SH III

 

Chronic Injuries

 

1.  Dynamic tendon transfer 

 

Adductor pollicis

- release adductor pollicis from ulnar sesamoid

- attach to base P1

 

2.  Free tendon graft

 

Graft options

- palmaris longus

- fourth toe tendon

 

Technique

- figure of 8 through drill holes

- transverse drill hole base P1

- drill hole head MC

- 6/52 POP

 

3.  Static tendon transfer

 

EPB

- leave attached distally

- weave through drill holes

 

Hand Arthritis

DDx DIPJ OA

DDx

 

OA

Psoriasis

CREST (scleroderma)

 

RA (rare form)

Other seronegative arthropathies

Hyperparathyroidism

Reactive arthropathy

Gout

 

 

 

Finger Osteoarthritis

EpidemiologyHeberden's Nodes

 

Male & Females > 60 years

- X-ray evidence of OA

 

Symptomatic 

- 25% females

- 15% males

 

Affected joints

 

Base thumb

PIPJ / Bouchard's nodes

DIPJ / Heberden's nodes

 

Finger OA

 

3 Groups

 

1.  Heberden's nodes

2.  Basilar thumb & Heberden's 

3.  Heberden's and Bouchard's

 

Xray

 

Joint space narrowing

Subchondral sclerosis

Osteophyte formation

 

DIPJ OAPIPJ OA

 

Management

 

Options

 

Arthrodesis

Arthroplasty

 

DIPJ Arthrodesis

 

DIPJ OA

 

Position

- 15 - 20o flexion

 

Incision

- transverse incision over DIPJ / H

- split / divide extensor tendon

- resect with small bone cutters and nibbles

 

Options

 

A.  Headless compression screw

 

DIPJ Fusion ScrewDIPJ Fusion Screw 2

 

B.  K wire and TBW

- single intra-axial K wire

- pass retrograde first, reduce, anterograde

- Circular wire

- small drill holes and pass 25 or 26 gauge wire

- tension

 

DIPJ FusionDIPJ Fusion TBW Lateral

 

PIPJ Arthrodesis

 

Best in RF / LF

 

Position

 

IF / MF

- 25 - 35o

 

RF / LF

- 45 - 50o

 

Technique

 

Longitudinal incision

 

Options

 

A.  Reflect central slip

- leave attached distally

- lateral bands remain 

- suture repair at end

 

B.  Interval between central slip and lateral band

- reflect central slip laterally

 

Release collateral ligaments

- leave volar plate intact

- create two opposable surfaces

- saw or bone nibbler

 

Fixation

 

A.  Headless compression screw

 

B.  Crossed K wires

 

C.  Longitudinal K wire and TBW figure 8

- pass wire retrograde 

- reduce, pass distally into P2

 

PIPJ Fusion TBWPIPJ Fusion TBW 2

 

Results

 

Fusion rates about 90%

 

Arthroplasty

 

See rheumatoid hand discussion

 

 

Inflammatory Arthritis

Conditions

 

Acro-osteolysis

SLE

Scleroderma

Psoriasis

 

Acro-osteolysis

 

Definition

 

Absorption of distal tuft of phalanx

 

DDx

 

Psoriasis

Scleroderma / Raynauds

Frost Bite

Hyperparathyroidism

Diabetes

Vasculitis

Leprosy

RA rarely

Gout

 

SLE

 

Pathology

 

Similar hand appearances to RA

- no joint destruction even in setting gross deformity

 

Pathophysiology

 

Autoimmune disorder

 

Distension of joint from synovitis rather than destruction of joint

 

Pannus not as aggressive as RA

 

Symptoms

 

Migratory poly arthralgia

Flexor tenosynovitis

MP and PIP arthritis

Raynaud's

AVN of carpus

 

Other

- butterfly rash

- lymphadenopathy

- pleuritis / pericarditis / Glomerulonephritis

- haemolytic anaemias

 

Xray

 

Effusions

Juxtacortical osteopenia

Subluxation / dislocation

Bone infarction and abnormal calcification

 

Joint destruction = Co-existent RA

 

Diagnosis

 

ANA 

dsDNA

 

Management

 

Aimed at rebalancing soft tissues

- may be inadequate

- may have to resort to fusion

 

Scleroderma

 

Pathophysiology

 

Hand Sclerodermad Scleroderma Occluded Superficial Palmar Arch

 

Autoimmune disease

Unknown aetiology

Small vessel disease

Fibrosis in multiple organ systems

 

DDx

 

RA

- 40% patients have RF

 

Epidemiology

 

Patients female and middle ages

 

CREST Syndrome

 

1. Calcinosis

2. Raynaud's

3. Esophageal Strictures

4. Sclerodactyly

5, Telangiectasia

 

Hands

 

Stiff shiny digits

Loss of creases

Acral tapering of digits

Autoamputation (acro-osteolysis)

Telangiectasia

Calcium nodules

 

Extraskeletal 

 

Lung fibrosis

CRF

 

X-ray

 

1.  Calcium subcutaneous / extra - articular / occasionally intra-articular 

2.  Acro-osteolysis of the tufts of DP (80% patients)

 

Osteopenia

 

Joint erosion

- RA part of DDx

 

Resorption of thumb CMC

- subsequent radial subluxation of the thumb MC

 

Psoriasis

 

Psoriatic arthritis

 

Pathophysiology

 

Autoimmune disease

- seronegative arthritis

 

5-10% of RA have psoriasis

 

DDx from RA

 

Asymmetrical distribution

Seronegative

Psoriatic rash

Nail changes / pitting

 

Often less aggressive

- typically DIPJ more involved

- may have less synovitis but bone and soft tissue destruction still occur

 

Classification

 

1.  Classic - involvement of DIPJ joints of hands

2.  Deforming - with ankylosis & arthritis mutilans

3.  RA - Like - similar to RA but without RF

4.  Monarthritis

5.  Ankylosing Spondylitis - like

 

Hand X-ray

 

Periarticular phalangeal erosions

- asymmetrical

- no periarticular osteopenia

 

Periosteal new bone formation along MC / MT shafts

 

DIPJ

- typical 'Pencil in cup' deformity of DIPJ

- P3 tuft resorption & whittling

 

DIPJ Pencil in Cup

 

Juvenile Rheumatoid Arthritis

 

Differences from Adult RA

 

Usually much milder course

- 50-70% achieves remission

 

Deformity often opposite of Adult

- short ulna

- ulna hand / MC's

- radial deviation of fingers

 

Hands

 

Boutonniere deformity common

Intrinsic tightness uncommon

 

Extensor tenosynovitis signs uncommon

First sign is usually rupture of tendons with dropped wrist

 

 

Hand Infection

Bites

 

Human / Tooth Knuckle Injuries

 

Mechanism

 

Clenched knuckle

- tooth often penetrates capsule of MCPJ (60%)

- can injure the bone (58%)

- usually 3 / 4 th MCPJ

 

Associated Injury

 

Boxer's fracture

- 4th / 5th metacarpal head

 

Extensor tendon Laceration

 

Pathology

 

Up to 50% rate of infection

- septic arthritis

- tenosynovitis

- osteomyelitis

 

Organisms

 

Polymicrobial

- streptococci

- Staphylococci

- Eikenella

- anaerobes

 

Eikenella corrodens

- seen in 1/4 TKI

- gram negative rod / facultative anaerobe

- acts synergistically with strept and contributes to morbidity

- can be resistant to dicloxacillin

- usually sensitive to

 

Management

 

Intial treatment

- povidone-iodine + copious irrigation

 

Antibiotics

- augmentin oral

- IV penicillin

 

Surgery

- best to debrige and washout all wounds

- open skin

- inspect extensor tendon

- open capsule, washout +++

- closure capusle

- leave skin open

- day 2 steristrip skin close

 

Await cultures

- change antibiotics accordingly

 

Note

- failure of treatment with cephalosporin

- may be due to eikenella

- change to penicillin

 

Dog bites 

 

Organisms

 

Mixed growth

- Streptococci

- Staphylocci

- Pasteurella

 

Management

 

Washout & debride

Augmentin

TMP-SMX if allergic to penicillin

 

Cat Bites

 

Organisms

 

More often become infected

 

Culture

- 50% Pasturella multocida

 

Management

 

Incision and drainage

 

Antibiotics

-  Augmentin / penicillin

- 2nd or 3rd generation Cephalosporin

 

 

Felon

Definition

 

Abscess of terminal pulp

 

Aetiology

 

Puncture wound

Paronychia or subungual abscess

 

S. aureus most common

 

Management

 

Early Antibiotics and elevation

 

Usually requires incision and drainage

 

Incision 

- lateral aspect of pulp

- unilateral longitudinal incision

- non-contact side of digit

- not too volar otherwise knocks out vessels

- must divide fibrous septa

 

 

 

Flexor Tendon Sheath Infections

Aetiology

 

S. aureus / Strept

- usually a history of trauma

 

Anatomy

 

IF / MF / RF

- extend from DP to distal crease

 

LF

- extends to mid palm

- communicates with ulna bursa

 

Thumb 

- distal phalanx to volar wrist crease

- communicates with radial bursa

 

Examination

 

Kanavel's 4 signs

 

1.  Tenderness along course of flexor tendon

2.  Fusiform swelling

3.  Flexed attitude to finger

4.  Pain on passive extension of finger

 

Management

 

Early

- may settle with antibiotics if get early

- want improvement in 12 - 24 hours

- risk adhesions / tendon necrosis

 

Surgical 

 

Distal incision

- distal finger crease

 

Proximal incision

- distal palmar crease

 

Will see pus

- take swab for MCS

 

Pass infant feeding catheter

- into flexor sheath

- irrigate +++

 

IV ABx 48 hours

 

Occupational / hand therapy to prevent adhesions

 

 

 

Other

Radial & Ulnar Bursal Infections

 

Bursal Anatomy

 

Enclose flexor tendons

 

Ulnar bursa is extension of little finger synovial sheath

 

Radial is extension of thumb synovial sheath

 

Coalesce in carpal tunnel to envelope all flexors

- 50% of time radial and ulna bursa communicate

- can get horse shoe collections

 

Deep Space Infections

 

Clinical

 

Palmar pain and swelling

 

Dorsal pain and swelling

 

Anatomy

 

Midpalmar septum

- to MF Metacarpal

 

Hypothenar septum

- to LF Metacarpal

 

Potential Spaces

- thenar space

- midpalmar space

 

Thenar space

- ulnarly by midpalmar septum

- dorsally by Adductor Pollicis

- palmarly by index finger flexor tendon

 

Drainage

- dorsal incision (can spread to involve 1st dorsal interossei)

- palmar incision

 

Midpalmar Space 

- Radial border midpalmar septum

- Ulnar hypothenar septum

- Dorsally 3-5 metacarpals

- palmar flexor tendons and lumbricals

 

Management

- transverse incision across palm

 

Web Space Infection

 

Boundaries

- dorsally web skin

- Volar by transverse palmar fascia

- Radially and Ulnarly by fibrous septa

 

Management

- both dorsal and volar incisions to ensure adequate drainage

- Avoid transverse incisions --> Contracture

 

Herpetic Whitlow

 

Aetiology

 

Cut on finger

- exposed to oral secretions

 

Symptoms

 

Often extremely painful

 

Management

 

Oral antivirals

Recurrence 30 - 50%

 

Atypical Mycobacterium

 

Aetiology

 

Mycobacterium marinum

- aquatic trauma

 

Clinical

 

Abundant tenosynovitis or joint synovitis

 

May take 8 weeks to culture on LJ medium

 

Management

 

Debridement

3-6 months ABx

 

 

Paronychia

Definition

 

Paronychia is skin around nail plate

 

Eponychia is skin covering base of nail plate

 

Pathology

 

1.  Due to foreign material between nail plate and paronychium 

 

2.  By hang nail traumatising paronychium

 

Aetiology

 

Acute

- typically polymicrobial 

- aerobes and anaerobes

- Staph aureus, group A Strep, Eikinella corrodens

- Bacteroides, gram positive cocci and Fusobacterium nucleatum

 

Chronic paronychia

- atypical mycobacterium

- fungal infection

- gout

- carcinoma

 

Management

 

Non operative

- warm soaks

- splinting 

- antibiotics (Augmentin)

 

Operative

 

Decompress and drainage of abscess may be necessary

- lift nail fold off plate +/- wedge resection

- avoid eponychial nail fold incision

 

Metacarpal Fractures

Fractures

 

1.  Neck of 5th Metacarpal

2.  Metacarpal Shaft

3.  Metacarpal Head

4.  Base of Metacarpal Fracture Dislocations

5.  Base of Thumb Fractures / Bennett's / Rolanda

 

1.  Neck of 5th Metacarpal Fracture

 

Non operative Management

 

Accept 45o angulation

- will have finger extensor lag, but will recover

- can ring block and manipulate in POSI cast to improve position

 

Neck of Fifth Metacarpal Fracture

 

Operative Treatment

 

Rare

- K wire across MC head into 4th MC

 

2.  Metacarpal Shaft Fracture

 

Acceptable Deformity

 

Rotation < 5o

10o / 20o / 30o / 40o in IF / MF / RF / LF

< 5 mm shortening

 

Metacarpal Fracture Minimally Displaced

 

Operative Management

 

Options

- plate

- lag screws (if spiral fracture)

- intramedullary wires

 

Metacarpal Intramedullary Wires

 

3.  Metacarpal Head Fracture

 

Epidemiology

- uncommon

- usually in index finger

 

Indication for surgery

- > 2mm angulation

 

Options

- T plate

- headless compression screws / intra-articular

 

4.  Base of Metacarpal Fracture Dislocations

 

Can be missed

- may need CT to diagnose

 

Management

- reduce joint closed +/- open 

- dorsal approach

- K wire

 

Metacarpal Base Fracture Dislocation APMetacarpal Base Fracture Dislocation LateralBase of Metacarpal Dislocation CT

 

5.  Base of Thumb Metacarpal

 

Types

A.  Bennett's

B.  Rolando

- Y shaped intra-articular

 

A.  Bennett's Fracture

 

Bennetts Fracture APBennetts Fracture LateralBennetts CT

 

Fracture

- oblique intra-articular fracture

- small volar fragment remains in situ as attached to beak ligament

- metacarpal displaces proximally and dorsally due to APL

- inherently unstable

 

Management

- closed reduction

- longitudinal traction on metacarpal

- use thumb to reduce metacarpal shaft

- use 2 x K wires to pin metacarpal to trapezium / trapezoid

- 6 weeks in thumb spica cast

 

Bennetts FractureBennetts K wireBennetts ORIF

 

Bennett K wires

 

B.  Rolando Fracture

 

Fracture

- 2 small intra-articular fragments

- poor prognosis

 

Operative management

- for significant displacement

- dorsal approach

- protect superficial radial nerves

- between APL / EPB and EPL

- attempt to anatomically reduce and fix with plate

Nail Bed Lacerations

Subungual haematoma 

 

Management

- < 50% of nail bed -> Decompress with needle

- > 50% -> remove nail and repair bed

 

Nail bed lacerations

 

Options

 

1.  > 50% nail lost

- will get hook nail

- ablate nail bed

 

2.  < 50 % nail lost

- repair bed under magnification

- 6.0 chromic cat gut

- reduce nail plate back into fold to prevent adherence of dorsal and ventral folds

 

3.  Matrix defects

- can place nail bed material in place without sutures

- can use split thickness free nail bed graft

(i.e. from amputated digit)

 

4.  Proximal avulsion of nail plate

- always have germinal matrix laceration

- should always have 3 x horizontal mattress sutures

 

Complications

 

Hook Nail

 

Hook NailHook Nail

 

 

Replants

Replant 4 FingersReplant 4 fingers post

 

Definition

 

Replant

- reattachment of body part that has been completely severed

 

Revascularisation of incomplete Amputation

- vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results

 

Mechanism of injury

 

Guillotine

Crush

Avulsion

 

Indications - Urbaniak 1987

 

Thumb 

Multiple digits

Individual digit distal to FDS insertion

Partial hand / through palm

 

Almost any body part in child

 

Wrist or forearm

 

Above or below Elbow 

- only if sharply demarcated

 

Contra-Indications

 

Adult single digit proximal to FDS insertion

- poor results / stiffness

 

Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time

 

Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time

 

Severe crush or mangled

 

Levels

- through elbow

- high arm

 

Multiple level / segmental injury

 

Other serious injuries/diseases

 

Vessels atherosclerotic

 

Mentally unstable patient

 

Examination 

 

Chinese red line sign 

- red streak along arterial course

- due to severe traction

 

Ribbon sign

- elongated tortuous arteries with pigtail appearance

 

Considerations

 

Thumb

 

Thumb has first priority

- a successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful

 

Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

- all efforts should be made to preserve thumb length even up to nail base

 

Multiple amputations

 

Replant best digit to most useful stump

When thumb intact goal is to restore palm width

 

Single digit

 

Does well if FDS intact

- allows immediate mobilisation of digit

 

P1 replants

 

Useful function does not occur

- patient will bypass finger

 

Mid-palm amputations 

 

Absolute indication for replant 

- replant far superior to prosthesis as lose sensation and power grasp

 

Proximal injuries

 

Proximal forearm, EJ and Arm 

- usually avulsion types with extensive muscle injury

- infection and muscle necrosis very common 

- usually replant not indicated

 

Patient factors

 

High demand professionals 

- may push indications eg at P1

 

Age is not a barrier 

 

Patient must be aware of chance at viability, function, time off work etc

 

Premorbid conditions must be taken into account 

- DM, Smoking, HTN, peripheral vascular disease

- patient compliance

 

Ischaemia

 

Key factor in success

 

Duration of allowed ischaemia varies from tissue to tissue

 

Recommended maximum

 

1.  Distal to carpus 

- 12 hours warm, 24 hours cool

 

Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

- digits have survived for 12 hours or longer of warm ischaemia

- when cooled replants have been performed at 36 hours

 

2.  Proximal to carpus 

- 6 hours warm, 12 hours cool

 

Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

- because of the size of the extremity only its outer part is adequately cooled 

- the deep muscle remains relatively warm

- the allowable 6 hours can't be extended

 

Transport of part

4oC ideal

 

2 Methods

 

1. Wrapping the part in a moistened cloth of Ringer's or Saline

- placing in plastic bag and placing the bundle in ice water

 

2. Immersing the part in one of these solutions in a plastic bag 

- then putting on ice

 

No difference in outcome

 

Most important is to give clear and precise instructions to referring doctors

 

Surgeon

 

Dedicated replant team

 

Should be able to consistently achieve 90% patency rate in 1mm vessels in labratory

 

Operating theatre not the setting for practice

 

Surgical management

 

Operative Sequence for single digit

 

1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage

 

Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis

- IDC

 

Approach

- longitudinal mid-lateral incisions for digital replants

 

Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1cm each side

- alternative is to vein graft but is easier to shorten bone

- Shortening also helps with skin coverage

- ORIF P1

- K wire fusion DIPJ / P2

 

Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair

 

Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 

 

Vascular

- 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise vein graft

- tourniquet acceptable

- micro-clips / bulldog clips should not be applied > 30min due to intimal damage

- heparin boluses to maintain patency (5000IU in 500 mls)

- papaverine antispasmodics

- 2 veins for every artery

 

Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft if not 

- use medial cutaneous nerve of forearm 

 

Skin

- skin closed under no tension

- digital incisions often left open to decompress repairs

- fasciotomies in larger replants

- bulky above EJ dressing with volar slab unless flexor tendon repair then dorsal slab

 

Replant at level of nail bed

 

Issue

- No dorsal veins 

 

Options

1.   Repair of volar veins (smaller and more flimsy)

2.   Anastomose one distal artery to proximal vein (AV anastomoses)

3.   Backbleeding by removing nail plate and scrapping every 2 hrs with cotton applicator and heparin dressings

4.   Medical grade leeches

 

Post-Op

 

Elevate gallows

- high dependency area

- high fluids

- anticoagulation controversial

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

- colour, pulp, turgor, cap refill, and warmth all used as aids in monitoring the replant

- observations hourly for 72h then q4h

- if concern re myoglobinuria then maintain urine output high and alkalinise the urine

 

Monitoring

- if surface temperature <30°C poor perfusion of replant is certain

 

Reversal of failing patient

 

If appears threatened immediate action necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

6. If return to OT necessary then must be within 4-6 hours of ischaemia

 

Results

 

80-85% survivability

 

Urbaniak 1985

- 51/55 survived

- ROM 82o distal to FDS

- 35o proximal to FDS

 

Ring Avulsions

 

Urbaniak Classification

 

I - circulation adequate

II - circulation inadequate

III - complete degloving / amputation

 

Major limb replantation

 

Issues

 

Amputations proximal to metacarpal level have significant muscle bulk

- to prevent myonecrosis immediate arterial inflow is necessary

- following rapid skeletal stabilisation at least one artery must be stabilised then follow sequence for digit

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc

- return to OT at 72 hrs for inspection and DPC

 

2 most common causes of failure in major limb replants 

 

1.  Myonecrosis with subsequent infection

 

2.  Failure to adequately decompress the restored vessels

 

Rheumatoid Hand

Hand RA Exam

Screening of Joints

 

Neck

-  ROM

 

Shoulder

- behind head / to mouth

- to back pocket 

 

Elbows

- flexion / extension elbows 

- pronation / supination with thumb up & elbows by side

 

Wrist

- flexion / extension

 

Hand

- make fist with thumb in and out 

- spread fingers

 

Functional Assessment of Hand

 

Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch

 

1.  Tip to Tip Pinch Grip

- pick up coin 

 

2. Lateral pinch grip

- turn key

 

3. Precision grip

- write with pen

 

4.  Power Grip

- turn knob 

 

5.  Hook Grip

- hold suitcase / fingers

 

Look at Hands / Place on Pillow

 

Palms up

 

Scars

- CTD / flexor tendon synovectomy

Swelling

- flexor sheath synovium

Thenar & Hypothenar eminences

 

Thumb up

 

Thenar wasting

Swan neck / Boutonniere deformity

 

Rheumatoid thumb Boutonneire

 

Palms down

 

Rheumatoid Hand

 

Wrist 

- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 

 

MCPJ 

- ulna drift / replacement / synovitis

- tendon subluxation

 

Fingers

- Swan neck / Boutonniere deformity

- rheumatoid nodules

 

Rheumatoid Nodules

 

Feel

 

Sensation

- median nerve / CTS

- ulnar nerve

 

Move

 

Extensor tendons

- drop fingers

- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy

 

EPL

- ruptures over Listers

- IPJ is extended by intrinsics also

 

Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering

 

MCPJs

- ? subluxed

 

Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes

 

Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes

 

Swan Neck Finger 1Rheumatoid Swan Neck Finger 1

 

Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

- with tight interossei will have reduced PIPJ flexion with MCPJ extension

Management Summary

Rheumatoid Hands Xray

 

Rheumatoid Arthritis Diagnostic Criteria

 

1987 American College of Rheumatology 

 

Need 4/7 (MAX RANS)

1. Morning Stiffness

2. Arthritis of 3 areas > 6/52

3. Xray changes

4. Rh factor

5. Arthritis of Hand > 6/52

6. Nodules

7. Symmetric Arthritis > 6/52

 

Types of Surgery

 

5 basic Groups

 

1. Synovectomy / Capsulorrhaphy

2. Tenosynovectomy

3. Tendon surgery & soft tissue balancing

4. Arthroplasty

5. Arthrodesis

 

General Principles

 

Replace all MCPJs

Fuse IF/MF PIPJs

Replace RF/LF PIPJs

Fuse DIPJs

Correct wrist deformity at same time or risk recurrence

 

Caput Ulnae Syndrome 

 

Components

- volar subluxation of ulnar carpus 

- supination of carpus on wrist 

- apparent dorsal subluxation of distal ulna 

 

Nalebuff Classification MCPJ

 

Stage I - Synovitis

- medical Rx and splinting

- synovectomy

 

Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction

 

Stage III - Moderate joint destruction

- volar subluxation and ulnar drift

- soft tissue reconstruction possible

- arthroplasty gives more reliable results

 

Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases

 

Causes of MCPJ Deformity

 

Ulna Drift / Ulna Dislocation

 

1.  Physiological

- gravity

- lateral pinch pressure

 

2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)

 

3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation

 

Nalebuff Classification Thumb

 

Note: Type II now removed as Nalebuff later said doesn't exist

 

Type I - Boutonniere

- the commonest

- MCPJ flexion, IPJ hyperextension

 

Type II - Boutonniere & Swan Neck

 

Type III - Swan Neck

- second most common

- deformity is at CMC / Dorsal & radial subluxation

- hyperextension MPJ / flexion IPJ

 

Type IV - Gamekeepers

 

Type V - Stretched Volar Plate MCPJ

 

Type VI - Arthritis Mutilans

 

Swan Neck

 

Causes

 

DIPJ 

- terminal extensor tendon rupture or attenuated

- entrapped FDP

 

PIPJ 

- volar capsule stretching / FDS rupture

- contracted central extenor slip

 

MCPJ 

- intrinsic tightness 

- extrinsic weakness / MCPJ subluxation and subluxation extensor apparatus

 

Management

 

Flexible

- FDS tenodesis / Lateral band transfer

- DIPJ arthrodesis (mallet)

 

Intrinsic tightness

- above +

- intrinsic release

 

Fixed deformity

- PIPJ dorsal release

- then above

 

Arthrosis 

- arthrodesis (20/30/40/50)

- arthroplasty (LF / RF)

 

Boutonniere Finger

 

Problem

- rupture of central slip

 

Solution

- flexible - Matev's central slips reconstruction

- radial lateral band to central slip

- ulna lateral band to radial lateral band insertion

 

Rheumatoid Fingers

ConditionsBoutonniere Fingers

 

1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

- may get mallet

- arthrodesis

4.  Ankylosis

- arthrodesis / arthroplasty

5.  Unstable / flail

- arthrodesis usually best option

6.  Swan neck deformity

7.  Boutonnière deformity

 

Concepts

 

Boutonnière deformity

- usually good function

- often don't need surgical treatment

 

Hand Boutonniere Finger

 

Swan Neck

- much more debilitating

- usually need treatment

 

Swan Neck Deformity (Intrinsic Plus Deformity)

 

Deformity

 

Hyperextended PIPJ / MCPJ + DIPJ flexion

- Bunnell calls this "Intrinsic plus deformity"

 

Rheumatoid Boutonniere FingerRheumatoid Boutonniere Finger

 

Rheumatoid Finger Swan Neck XrayFinger Swan Neck

 

Cause

 

Primary process is usually synovitis

- starts at either MCPJ / PIPJ / DIPJ

 

DIPJ 

 

Dorsum

- terminal tendon ruptured or attenuated

 

Volar

- may also be due to stuck FDP

 

PIPJ 

 

Volar

- rupture of FDS due to synovitis

- volar capsule stretches due to synovitis 

 

Dorsum

- contracted central extensor slip

 

MCPJ 

 

Extrinsic

- relative shortening of long extensors

 

Intrinsic 

- relative intrinsic tightness

- also seen in CP / CVA

 

Articular 

- destruction or deformity

 

Rheumatoid Swan Neck secondary to MCPJ

 

Nalebuff Classification

 

Function depends upon PIPJ flexion

 

Bunnell Test

 

Assess Interossei Tightness

 

Positive test 

- PIPJ flexion less in MCPJ extension than with MCPJ flexion

- interossei are tighter in extension

- invalidated by MCPJ dislocation

 

Test

- hand dorsum up

- correct ulna deviation

- extend MCPJ & comment on active PIPJ range

- flex MCPJ & comment on active PIPJ range

 

Type I

- PIPJ passively correctable / regardless of MCPJ position

- Bunnell Test negative

 

Type II

- PIPJ flexion limited with extension of MCPJ

- Bunnell Test positive

- intrinsic tightness

 

Type III

- fixed PIPJ flexion regardless of MCPJ position 

- joint problem

- lateral bands dislocated dorsal to axis of rotation

 

Type IV

- joint destruction / X-ray arthritis

 

RA Swan Neck Fingers XrayRheumatoid PIPJ Destruction

 

Management

 

Aim is to create FFD

- many techniques described

 

Type 1

 

A.  Create FFD by FDS tenodesis

- use slip of FDS

- detach proximally

- pass through A2 pulley and attach to bone or on itself

- producing 20° FFD

 

+ DIPJ fusion

 

B.  Zancoli lateral band transfer

 

Lateral bands mobilised volar to axis of PIPJ

- raise flap of flexor retinaculum

- suture over lateral band to fix in place

- dorsal blocking splint / K wire

 

+ DIPJ fusion

 

Type II

 

Above +

 

Intrinsic release

- division of intrinsic oblique fibres

 

Anatomy

- oblique fibres which extend IPJ /  interossei

- transverse fibres flex the IPJ / lumbricals

 

Type III

 

PIPJ release first / Lateral band tenolysis / K wire

- release central slip / dorsal capsule / collateral ligs to allow flexion to >90o

- manipulate joint to flexed position

- fix with K-wire

- often stiff due to flexor synovitis

- often need flexor sheath synovectomy to get moving

 

Type IV

 

Arthroplasty RF / LF for grasp 

- arthroplasty has highest failure rate for Swan Neck 

- high recurrence and poor range

- 80% survival at 9 years

 

Fusion IF / MF for strength 

- angle of fusion a cascade 

- 20 30 40 50 (IF MF RF LF)

 

Rheumatoid Fusion PIPJ LF RF

 

Boutonniere's Deformity (Intrinsic Minus Deformity)

 

Boutonnierre Finger 1Boutonnierre Finger 2

 

Deformity

 

PIPJ flexed / DIPJ hyperextended /  MCPJ hyperextended

 

Often well tolerated & treatment not needed

 

Cause

 

1.  Central slip dysfunction

- always starts with PIPJ flexion 

 

2.  Lateral bands displace volar 

- secondary to triangular ligament stretching

 

3.  DIPJ hyperextends secondary to PIPJ flexion

- contracted oblique retinacular ligament

- becomes fixed

- examination finds limited DIPJ flexion with PIPJ in extended position

 

Nalebuff Classfication

 

Stage 1 

- mild extensor lag 10-15°

- passively correctable

 

Lateral band reconstruction

- reduce lateral bands dorsally

- suture together

 

Stage 2

- moderate 30-40° lag

- passively correctable

 

Lateral band reconstruction + Central slip shortening / reconstruction

 

Dorso-Medial Incision & Synovectomy

A. Reduce lateral bands dorsally & Suture together

B. Tenotomy Terminal slip

C. Central slip options

i)   Shorten 5 mm

ii)  Reconstruct with lateral bands (take inside half of each and suture together)

iii) Reconstruct with PL

iv) Matev central slip reconstruction

 

Matev Central Slip Reconstruction

- radial lateral band divided at level of P2 

- proximal stump rerouted through central slip 

- attached to base P2 at central slip insertion

- ulnar lateral band divided distally

- passed dorsally over P2 and attached to distal radial lateral band stump

 

Stage 3 

- severe 

- fixed with x-ray arthritic changes

 

Arthrodesis / arthroplasty

 

PIPJ replacement

 

Rheumatoid Arthritis PIPJ OA

 

Types

 

A. Pyrocarbon implants

- partially constrained press fit components

- relatively high failure rate

- can fracture when inserting and need cerclage wire

 

B.  Swanson spacer

 

Contra-Indications

 

Infection

Non reconstructable / irreparable

- extensor and flexor tendons

- collateral ligaments

 

Complications

 

Does not have same stability of MCPJ

- can dislocate

 

Technique

 

Dorsal incision

- straight or curved dorsomedially

- enter between central slip and lateral band

- can detach central slip proximally and reflect distally 

 

Release contractures

- balance soft tissues

- retain collaterals

 

Broach distally and proximally

- avoid extension at all times

 

Implant must achieve full extension

- no buckling, and no impingement

 

Repair central slip

 

Post op

- immobilise for 1 week

- dynamic extension splint 0 - 30o (Capner)

- active flexion

 

Arthrodesis PIPJ

 

Approach as above

- resect collaterals

- position as appropriate

- cross K wires / screw

Rheumatoid MCPJ

Deformity

 

Ulna drift & volar dislocation

 

Rheumatoid MCPJRheumatoid MCPJ Ulnar Deviation

 

Causes of MCPJ Deformity

 

Ulna Drift / Ulna Dislocation

 

1.  Physiological

- gravity

- lateral pinch pressure

- power grip

 

2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)

 

3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation

 

Nalebuff Classification MCPJ

 

Stage I - Synovitis

- medical treatment and splinting

- synovectomy

 

Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction

 

Stage III - Moderate joint destruction / Volar subluxation

- soft tissue reconstruction possible

- arthroplasty gives more reliable results

 

Rheumatoid Dislocated MCPJRheumatoid Dislocated MCPJ

 

Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases

 

Management

 

Stage I Synovectomy MCPJ

 

Indication

- marked synovial proliferation not responding to medical treatment

- 6/12 non-operative

- painful

- concern regarding progression to deformity

 

Contraindication

- joint destruction with articular erosion

- instability

- fixed deformity or dislocation

 

Technique

- incise hood on Ulna side extensor tendon

- make sure clear under volar plate & collaterals

 

Stage II Synovitis / Ulna Deviation / Preserved MCPJ  

 

Synovectomy + Soft Tissue Reconstruction

 

1.  Ulna side release 

- divide transverse, oblique & sagittal bands

 

2.  Crossed Intrinsic Transfer

- corrects ulna drift

- ulna side intrinsics are released 

- transferred to the Ulna neighbour radial intrinsics

- reinsert through radial lateral band

- use EI for Index attach to radial side

- release EDM at little

 

3.  Extensor Tendon Relocation

- ulna sagittal band release

- radial sagittal band tightening

 

Stage III / IV Destroyed MCPJ

 

RA MCPJ Arthritis

 

Arthroplasty + ST Reconstruction as above

 

Swanson Joint Replacement

 

Swanson's Indications

- fixed or stiff MCPJs

- x-ray shows destruction or subluxation

- ulnar drift not reconstructable

- contracted intrinsic and extrinsics

- associated stiff IPJs

 

Swanson's contraindications

- infection

- inadequate skin coverage

- poor NV status

- irreparable intrinsic/extrinsic system

- insufficient bone stock

 

Aim 

- painless joint with useful arc of motion

 

Results

 

ROM

- usually > 40°

- get about 10° improvement

 

Pain

- > 80% pain relief

- no increase in strength

 

Deformity correction

- up to 40% loss over time

- loss of correction often due to inadequate soft tissue balancing

 

Survival

- 90% 10 year survival

- silicon synovitis uncommon unlike for wrist or trapezial implants

 

Technique MCPJ Swanson Arthroplasty

 

Incision

- transverse incision dorsum

- full thickness flaps preserving dorsal veins 

 

Dissection

- incise extensor hood on ulna aspect each joint

- may need formal intrinsic release but bony cuts may be enough

- incise and remove capsule and synovitis

 

MC head

- excise MC head with osteotome or nibbler sufficiently to accept implant

- with final cut at 90° to shaft

- this often means removing collaterals

- ream MC with awl or drill

 

PI

- do not resect P1 base

- just ream with awl

 

Trial

- resection of bone should allow no buckling of implant 

- no impingement of MC on P1

- insert prosthesis proximal then distally

- should have passive motion of 90°

 

Soft tissue balancing

- ulnar intrinsic release

- crossed intrinsic transfer

- extensor tendon relocation

 

 

 

 

 

Rheumatoid Thumb

Nalebuff Classification

 

Type I - Boutonniere 

- commonest

- MP flexion /  IP hyperextension

- usually EPB rupture with EPL subluxation

 

Rheumatoid Boutonniere Thumb

 

Type II

- Boutonniere & Swan Neck

- doesn't exist according to Nalebuff

 

Type III - Swan Neck

- second most common

- primary deformity is OA and dorsal subluxation of CMC

- hyperextension MPJ / IPJ flex

 

Rheumatoid Thumb Swan Neck

 

Type IV - Gamekeepers

- due to MCPJ synovitis

- stretches UCL

- either synovectomy / UCL reconstruction

- or fusion

 

Rheumatoid Gamekeepers Thumb

 

Type V - Stretched Volar Plate MCPJ

- differentiated from Swan Neck by no CMC disease

- fusion of MCPJ

 

Type VI - Arthritis Mutilans

- destruction and instability MCPJ / IPJ

- arthrodesis only option

 

RA Thumb Destruction IPJ

 

Boutonniere Deformity

 

RA Thumb Boutonniere's

 

Aetiology

 

Synovitis of MCPJ

- extensor Hood stretched

- EPB ruptures

- EPL tendon displaced Ulnarward & Volarly

- becomes flexor 

 

Management

 

1.  Flexible MCPJ

 

A.  Synovectomy of MCPJ

 

B.  EI to EPB / EPL Centralisation

 

C.  EPL transfer + fusion IPJ

- divide EPL over P2 and reattach to base P1

- good correction early 

- but 66% recurrence

 

2.  Fixed MCPJ / Flexible IPJ

 

Arthrodesis / Arthroplasty MCPJ

- arthrodesis better suited for young, high demand

- arthroplasty better suited to low demand

 

Rheumatoid MCPJ Fusion

 

3.   Fixed IPJ and MPCPJ

 

A.  Fuse both 

- best option 

 

B.  IPJ fusion / MCPJ arthroplasty

- with arthroplasty have to balance soft tissues

- reroute EPL as above

 

Swan Neck

 

Aetiology

 

RA Thumb Swan NeckRA Swan Neck Deformity

 

Disease at CMCJ

- leads to dorsal subluxation of CMCJ 

- beak ligament is not functional

- result is adduction contracture

 

MCPJ hyperextension

- ? volar plate stretches

 

IJP flexion

- ? Mallet rupture 

 

Management

 

A.  Trapeziectomy and LRTI

 

Rheumatoid Swan Thumb Trapeziectomy

 

B.  +/- MCPJ fusion

 

Thumb MCPJ Fusion

 

Tendon Injuries

Extensor Tendon Injuries

Zones

 

I DIPJ

II Middle Phalanx

III PIPJ

IV Proximal Phalanx

V MCPJ

VI Metacarpal

VII Dorsal Wrist Retinaculum

VIII Distal Forearm

IX Mid & Proximal Forearm

 

MRI Wrist Extensor Compartments

 

Anatomy

 

Sagittal bands

- stabilise EDC

- extend MCPJ

 

Lateral bands

- lumbricals extended PIPJ

 

Zone 1 Mallet Finger

 

Clinical

- loss of extension of DIPJ

- +/- Swan neck deformity

- hyperextension of PIPJ due to unopposed central slip action 

 

Issues

 

Avascular region of tendon at insertion into DIPJ

- explains poor surgical results

 

Mechanism

 

Closed

 

1.  Forced flexion of extended digit

- Rupture of tendon

- Avulsion of tendon ± small fragment of bone

 

2.  Forced hyperextension of DIPJ

- fracture of dorsal base of P3

 

Open

- Laceration over dorsum of DIPJ

 

Types

 

Type I    

- closed trauma

- no bone or < 1/3

 

Type II  

- laceration

 

Type III  

- deep abrasion

 

Type IV  

A) Transepiphyseal plate fracture in children

B) > 1/3 of joint surface

C) > 1/3 + Volar Subluxation of P3

 

Management

 

1.  No or small Bony Lesion

 

Extension splint (Stack splint) for 6 to 8 weeks

- night splinting further 6 weeks

- 80% good results if treated early

- direct repair should be avoided (poor blood)

 

2.  Bony lesion > 50% with volar subluxation

 

A.  Extension splint

B.  ORIF

- poor skin, high risk of breakdown

C. Dorsal blocking K wire / second K wire across joint

 

3.  Chronic Mallet Finger 

 

1.  Arthrodesis 

- joint incongruent, arthritic or fixed

 

2.  Reconstruction possible if supple

 

4.  Open

 

Suture skin and tendon together

 

Zone 3 Boutonniere Lesion

 

Definition

- disruption of central slip at PIPJ

 

Mechanism

 

Closed

- forced flexion of PIPJ

- causes avulsion of central slip ± bony fragment

 

Open

- laceration over central slip

- similar progressive deformity

 

Pathology

 

Deformity usually not present at time of injury

- develops after 2-3/52

 

1. Flexion of PIPJ

- due to loss of central slip

- unopposed action of FDS

 

2. Stretching of expansion between central & lateral slips 

- transverse retinacular / triangular ligaments

 

3. Lateral bands migrate volar

- position volar to axis of rotation

 

4. Pull of lateral bands exclusively directed to DIPJ

- DIPJ hyperextends

 

5. MCPJ also hyperextends because of pull of long extensor

 

Examination

 

1.  Hold wrist and MCPJ fully flexed

- relaxes lateral bands

- unable to actively extend PIPJ

 

2.  Elson's test

- flex PIPJ to 90o over edge of table

- unable to actively extend PIPJ against resistance, will hyperextend DIPJ

 

Management

 

Closed

 

1.   Splint PIP in Extension 4/52

- Leave DIPJ free and allow ROM

 

2.  Capener Splint 4/52

 

Open

- central slip & lateral bands sutured with 5/0 nylon

- ff close to insertion, pull-out suture used

- PIPJ splinted in full extension for 6/52

- replaced with Capener splint when wound healed & sutures removed

 

Reconstruction

 

Palmaris longus weave

 

Extensor Tendon Repairs Zone 5 - 9

 

Prognosis

 

Excellent results of repair 5 proximal zones

Only 50% excellent results 4 distal zones

 

Surgery

 

Lacerations >50% zones V-VIII should be repaired

- modified Bunnell or Kessler best

- try to maintain length

 

Dynamic splinting 

 

Greatly improves results and is key 

- need 5mm excursion to prevent adhesions for flexors (Unknown for extensors)

- typical repairs shorten tendon

 

Outrigger with passive extension by rubber bands

- WJ 30o extension, MP's 10-15o flexion, IP's 0o

- allow 5mm excursion of tendon

 

 

Flexor Pulley Ruptures

Anatomy

 

5 Annular pulleys

3 Cruciate pulleys

 

Pathology

 

A1 and A5 expendable

 

Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3

 

Aetiology

 

Rock climbers

- usually when slipping

 

May hear or feel a pop

 

Develop swelling / tenderness / pain

 

Bowstringing

- usually only with multiple pulley rupture

 

Investigations

 

Xray

- exclude fracture

 

Ultrasound

- very good

 

MRI

- if US inconclusive

 

Grading

 

Grade 1

- strain

- A4 tear (has good prognosis)

 

Grade 2

- partial tear A2 or A3

 

Grade 3

- complete A2 or A3 rupture

 

Grade 4

- multiple pulley rupture

- +/- lumbrical avulsion or collateral ligament damage

 

Management

 

Non operative

 

Single complete pulley ruptures

- no climbing for 6 weeks

- gradual return to climbing with pulley taping

- full return to sport at 3 months

 

Operative

 

Multiple pulley ruptures

- repair techniques poor

- reconstruction required

- A2 with palmaris longus graft

- A3 with extensor retinaculum graft

 

 

 

Flexor Tendon Background

Anatomy

 

Fascicles of long, spiraling bundles

- tenocytes & Type I collagen

- synovial cells & fibroblasts present

 

Endotenon 

- surrounds the individual collagen bundles

 

Epitenon

- fine fibrous outer layer, highly cellular, continuous with endotenon

- contains most of the blood vessels & capillaries

 

Paratenon

- thin visceral layer of adventitia on tendon

- provides nutrition & allows gliding

 

Synovial Sheaths

 - in distal palm & fingers, visceral synovial layer enclosing FDS/FDP

- parietal layer continuous with the pulleys

- tendons attached via long & short vinculae

 

Pulleys

 

Thickenings of the synovial sheath

- 5 strong annular pulleys interposed by 3 collapsible cruciate pulleys 

- allow the annular pulleys to approximate in flexion

 

A2 & A4 

- fibro-osseous annular pulleys

- arise from periosteum of the phalanx

- maintain short moment arm of tendon from joint, greatest joint rotation for least excursion

- most important

 

A1, A3, A5 

- arise from the volar plates 

- MCPJ, PIPJ & DIPJ respectively

 

Palmar Aponeurosis Pulley 

- important additional pulley

- transverse fibres of palmar fascia

 

Thumb Pulleys

- A1 (MCPJ) and A2 (IPJ)

- Oblique pulley in between and is most important

- can be excised if A1 intact

 

Flexor Tendons

 

Excursion can exceed 8cm

- in pulley area flexor tendons have segments that are avascular  

 

Actions

 

FDS 

- arises from single muscle belly

- volar aspect of humerus, radius and ulna

- separates into 4 tendons in forearm

- IF and LF deep, RF and MF superficial in carpal tunnel

- LF may be absent (20%)

- bifurcates at level A1 pulley

- 2 slips rotate around and insert volar aspect base of P2 and radial / ulna sides

 

Action

- has independent action

- FDS & interossei combine for forceful flexion

- 200N achieved in power grip

 

FDP 

- has common muscle origin

- arises volar aspect ulna and interosseous membrane

- deep to FDS

- several digits have simultaneous action

- acts as primary digital flexor 

 

Lumbricals

- arise from FDP

- lateral 2 (ulna n) bipennate, medial 2 arise from 1 tendon only (median n)

- insert on radial side of extensor expansion

- flex MCPJ and extend IPJ's

 

Vascular Supply

 

Blood vessels

 

1. Longitudinal vessels enter tendons in palm

-  Vessels enter at proximal synovial fold in distal palm

 

2. Vessels enter at osseous insertions

 

3. Segmental branches of digital arteries enter via long & short vinculae

- VBP vinculae brevis profundus 

- VLP vinculae longus profundus

- VBS vinculae brevis superficialis 

- VLS vinculae longus superficialis

 

Flexor tendons have highest vascularity dorsally

 

Synovial Fluid Diffusion

 

May function better than vascular perfusion

- composition similar to joint fluid

- imbibition process

- fluid is pumped into interstices of tendon through ridges oriented at 90° to each other during flexion and extension

- synovial sheath is critical to this process

- lacerations disrupt this mechanism

 

Avascular segments

 

1.  FDS & FDP have avascular segments over proximal phalanx under A2

 

2.  FDP has 2nd avascular segment over middle phalanx under A4

 

Tendon Biochemical Composition 

 

Composition

- Type I collagen 95%

- Type III & V collagen 5%

 

Dense, parallel collagen fibres

- Highest tensile strength of all soft tissues 

- Collagen in triple helix of tropocollagen molecules 

 

Age and immobilization

- increases collagen content 

- loss of water content, glycosaminoglycan concentration & strength

 

Exercise training

- increases collagen fibril size

- increases strength & stiffness

 

Tendon Healing  

 

Both Intrinsic & Extrinsic factors

- extrinsic - fibroblasts and inflammatory cells from periphery

- intrinsic - fibroblasts and inflammatory cells from epitenon

 

Aim is to optimize intrinsic healing and minimize extrinsic healing which may lead to development of adhesions

 

3 Phases

- inflammatory

- fibroblastic

- remodelling

 

Inflammatory Phase Day 1-4

 

Clot fills defect

- Epitenon cells migrate into & bridge the gap

- Peritendinous cells proliferate & migrate into laceration site

 

Fibroblastic Phase Day 5-28

 

Collagen secretion begins by day 5

- fibres formed in random fashion

- Fibroblasts become the predominant cell type

- Synovium is reconstituted by day 21 

- Vascularisation increases with penetration of avascular zones by new blood vessels

- Increased strength by 2 - 3 weeks

- Collagen content increases for first 4 weeks

- Collagen reorientation complete by day 28

 

Remodelling Phase Day 28-112

 

By day 28 fibroblasts longitudinally oriented 

- progressive remodeling & realignment of collagen fibrils

- By 6 weeks gap is completely filled

- By 8 weeks collagen is mature & realigned

 

By 4 months

- maturation complete 

- fibroblasts now quiescent tenocytes

- Full tensile strength only reached after physiologic loading

 

Adhesions

 

Dense adhesive scar 

- results from ingrowth of fibroblasts from the digital sheath & epitenon proliferation

 

More severe 

- immobilized tendons

- increased severity of synovial sheath injury /crush

- gaps > 3mm

 

 

 

 

Flexor Tendon Complications

Complications

 

1.  Flexor Tendon Rupture

2.  Adhesions

3.  PIPJ contractures

4.  Triggering

5.  Pulley failure

6.  Quadrigia

 

1.  Flexor Tendon Repair Rupture

 

Incidence

 

5%

 

Management Options

 

FDS only

- usually minimal impairment

 

FDP only

- may be better to fuse DIPJ

- passing tendon through FDS may give poor result

 

FDP and FDS

- repair / graft FDP

 

One Stage repair

 

Indications

1. Minimal scarring

2. Pliable joints

3. Adequate retinacular pulley system

4. Not Zone 2

 

2 Stage repair  

 

Indications

 

1.  Severe adhesions or scarred tendon bed

2.  Contractures

3.  Disruption of pulley system

4.  Missed injuries

5.  Injuries not suitable for primary repair

- usually gross contamination

 

Technique 2 Stage

 

Concept

- all anastomosis in Zone 1 and Zone 3 (not Zone 2)

 

Technique Stage 1 

 

Long Brunner incision finger

- Scarred tendon remnants excised, contractures released 

- A2/4 pulleys reconstructed if necessary

- Silastic implant sutured distally to FDP Zone 1

- proximal end zone 5 free

- need incision in palm to pass through to forearm 

 

Mobilisation regime post-op

- get finger moving / passive exercises +++

- minimise adhesions

- recreate synovial sheath for second stage

 

Pulley reconstruction

- use FDS, extensor retinaculum, PL free tendon

- A2: passed dorsal to NV bundles between phalanx and extensor tendons

- A4: superficial to extensor tendons

 

Technique Stage 2 

 

Graft options

- Palmaris longus (absent 25%)

- Plantaris (absent 20%)

- Long toe extensor (IV)

 

Timing

- performed at 3 months 

- Early, protected Post-op mobilisation

- active motion at 4 weeks

 

2.  Flexor Tenolysis

 

Diagnosis Flexor Tendon Adhesions

 

Limited active ROM > passive ROM

- tendon adhesions

 

Limited passive ROM = active ROM

- joint contracture

 

If there is a marked difference between active and passive ROM

- adhesions likely but

- need to ensure repair is intact

- feel for tendon / ultrasound

 

Timing

 

Up to 20% of patients require tenolysis

- therapy +++ for 3 - 6 months

- need to assess the amount of functional deficit of the patient

- subcutaneous tissues must be state of equilibrium (i.e. soft and supple)

 

Technique

 

Must be prepared to go on to 2-stage repair

- long brunner incision

- access tendon through sheath via less important pulleys

- early active ROM critical

 

3.  PIPJ Contractures

 

Non Operative

 

Splints

- static night time extension splints

- dynamic external fixators

 

Therapy

 

Operative

 

Access between A2 and A3 pulley

- remove cruciform pulleys

- flexor tenolysis

- release check rein ligaments

- release accessory collateral / collaterals / volar plate

- MUA

 

Results

 

Improve extension 20 - 30o

- lose equivalent amount of flexion

- change functional arc

 

4.  Triggering

 

May be triggering on A2 or A4 pulley

- Non operative treatment

 

5.  Pulley Failure and Bowstringing

 

6.  Quadriga

 

Issue

 

FDP of MF / RF / LF linked

- will only extend as much as of shortest tendon

- if limited excursion of one FDP due to repair etc

- present with limitation of all finger flexion

 

Solution

 

Release adhesions of the shortened tendon

 

 

Flexor Tendon Repair

Concepts

 

1. Core suture

 

Strength of repair proportional to

A.  Number of strands crossing the gap (not suture type)

B.  Suture size (usually non absorbable braided suture 3/0 or 4/0)

 

2. Repair strength increases more rapidly with early motion stress

 

3. Dorsal sutures are stronger but may interfere with blood supply

 

4. Repairs usually rupture at knots

 

5. Locking loops decrease pull out and increase strength

 

7. Peripheral Circumferential Suture 

- increases repair strength by 10-50%

- reduces gapping and bulk of repair significantly

- closure of epitenon with 6/0 suture

 

Partial Tendon Lacerations

 

< 25%

- debride

 

25 - 25%

- epitenon repair

 

> 50%

- core and epitenon repair

 

Early ROM Rehabilitation

 

1.  Load at failure at 3 weeks 

- immediately mobilised tendons 3 x > immobilised tendons

- more rapid collagen realignment

- histological exam increased healing response with decreased scar response

 

2.  Early mobilization decreases adhesions

 

Early Active ROM Protocol 

 

Position in extension blocking splint

- wrist and MCPJ flexed

- DIPJ and PIPJ in extension

 

Stage 1

- passive flexion using the other hand (5 times per hour)

- active extension of finger in splint

- splint never removed

 

Stage 2

- once full passive motion gained (each hour)

- 5 x passive finger flexion & active extension

- 5 x active finger flexion & 5 active finger extension

- splint never removed

 

6 Weeks

- splint removed & active wrist movement

- no resistance

 

8 weeks 

- resistive work (sponge squeezing)

 

12 Weeks 

- normal activity

 

Incisions 

 

Brunner incisions

- incorporate laceration

- avoid sharp angles <60o

- longitudinal incisions over flexor creases avoided

 

Identify and protect NV bundles

 

Expose synovial sheath

- preserve A2 and A4

- can remove other pulleys

 

Zones of Injury

 

Zone 1 

- distal to FDS (FDP only)

 

Zone 2 

- between A1 pulley and FDS insertion (2 tendons in sheath)

 

Zone 3 

- in palm, lumbrical origin

 

Zone 4 

- in carpal tunnel

 

Zone 5 

- proximal to carpal tunnel

 

Management

 

Zone 1

 

Causes

 

1.  Open / laceration

 

2.  Rugger jersey finger

- most common RF

- caught in jersey whilst grasping

- RF forcibly extended at DIPJ while FDP is contracting maximally

- due to common muscle belly for FDP to LF, RF, MF

 

Types

 

Avulsion FDP Type 1

- FDP retracts into palm

- vinculum ruptured

- tender swelling in palm 

- may need separate palmar incision

- need to pass under A2 and A4 pulley

- suture tendon to paediatric feeding catheter

- must be repaired in 7-10 days

 

Avulsion FDP Type 2 

- most common type

- retracts to PIPJ level

- vinculum intact

- swelling at PIPJ level

- early reinsertion best

- can be repaired up to 3 months after injury 

- may progress to type 1 injury if vinculae give way

 

Avulsion FDP Type 3 

- large bony fragment

- A4 pulley catches fragment & prevents retraction

- early reattachment

 

Repair

 

1.  Tendon to tendon repair

- if possible

 

2.  Insufficient distal tendon

- prepare bony insertion

- modified Kessler into tendon

- pass suture ends through distal phalanx and nail plate

- tie over button

- use 4.0 monofilament i.e. prolene

- need to remove button and sutures at 8/52

 

3.  Bony avulsion

- ORIF / button repair

 

Zone 2 / Bunnell No Man's Land

 

Problem

- both tendons injured

- high risk of bulky repairs / adhesions / poor function

 

Technique

 

Tendon laceration

- usually distal to skin cut

- need to retrieve tendons from palm

- A2 & A4 pulleys need preservation

- FDS & FDP both repaired if possible

- may only need one limb of FDS

 

Core Suture

- 2 x modified Kessler

- can use 2 x loop sutures to create 4 strand modified Kessler

- best to use prolene as will run easier than polyfilament suture

 

Peripheral suture

- 6.0 prolene running suture

- do dorsal aspect of tendon first, then core, then complete volar aspect

- very important for strength and allowing smooth glide

 

Zone 3

 

Delayed repair up to 3 weeks possible 

- lumbrical holds tendon 

- relatively good prognosis

 

Zone 4

 

Rigid compartment

- good result more difficult to achieve

- often complicated by median nerve injury

- should repair within 3 weeks to avoid myostatic muscle contraction

 

Zone 5 

 

Loose compartment

- good prognosis but associated nerve injuries important prognostically

- quality of repair not so important

- should repair within 3 weeks otherwise muscle contraction occurs

 

 

 

 

 

Thumb Radial Collateral Ligament

DefinitionRadial Collateral Ligament Avulsion

 

Also known as Chauffeur's Thumb

 

Epidemiology

 

Much less common than UCL injuries

 

Issues

 

Rarely get soft tissue interposition

 

Management

 

Chronic Instability

 

1.  Repair scarred ligament

 

2.  Reconstruct with graft

 

3.  Advance Abductor pollicis

- reinsert 10mm more distally on P1

 

 

Tumours of the Hand

Enchondroma

Epidemiology

 

Most common bony tumour of hand

 

Risk malignant transformation isolated lesion is < 2%

- more likely in long bones than hands

 

Site

 

Proximal phalanx > middle

 

Syndromes

 

Ollier's

- multiple enchondromatosis

- risk of transformation 10 - 25%

 

Maffuci's

- enchondromas and hemangiomas

- risk transformation close to 100%

 

Prognosis

 

Observation unless

- pain

- aggressive X-ray changes

- increased uptake on bone scan

 

Biopsy to exclude malignancy

 

Pathological fracture

 

Allow fracture to heal

- enchondroma does not resolve

 

Curette and bone graft at a later date

 

Epidermal Inclusion Cyst

Epidemiology

 

Most frequent tumour around distal phalanx

 

M>F 2:1

 

Mean age 3rd decade

 

Aetiology

 

Likely traumatic 

- subcutaneous implantation of keratinising epithelium that continues to grow and produce keratin

 

Clinical

 

Painless firm swellings

Most common volar aspect P3 index / middle

 

X-ray

 

Round / oval lesion in P3

- thinning of cortex

 

Epidermal Inclusion Cyst

 

Pathology

 

Fibrous capsule with keratin filled space

Squamous epithelium

 

DDx                       

 

Foreign Body Granuloma

 

Management    

 

Curettage and bone grafting (if bony)

 

Excision of lump

- recurrence very unusual

 

 

 

Ganglion

Epidemiology

 

Most common tumour of hand

F > M

2nd - 4th decade

 

Aetiology 

 

Unknown 

 

Trauma

Mucoid degeneration of collagen tissue

Synovial herniation

 

Location

 

1.  Dorsal

- scapho-lunate ligament 

- radial to EDC

 

2.  Volar

- scapho-trapezial joint 

- between FCR and APL

 

3. Retinacular

- along flexor sheaths 

- A1 / A2 pulley

 

4. Mucoid cyst

- associated with DIPJ OA and osteophyte

 

Recurrence rate

 

Dorsal 5%

 

Volar 20%

 

Clinical

 

Most asymptomatic

- soft to firm

- 1-3 cm

- transilluminate

 

Mucoid cyst can groove nail bed

- important to remove osteophyte as well to prevent recurrence

 

Pathology

 

Cyst

- cavity lined by epithelium

- viscous mucin

- hyaluronic acid

 

Management

 

Non - operative

 

Aspiration + HCLA injection

- usually needs multiple attempts

 

Operative

 

Excision of ganglion

- find neck and dissect down to capsule

- remove capsular window

 

1.  Dorsal SLL

 

Technique

- radial side EDC

- protect SRN

- follow down

- excise neck and capsule

 

2.  Volar STJ

 

Technique

- between FCR and radial artery

- protect palmar branch median nerve

 

Complications

 

Recurrence

Nerve injury

Stiffness

Tendon damage

 

 

 

Giant cell tumour of tendon sheath

Definition

 

Benign tumour that arises from synovial tissues

- found near synovial-lined tendon sheaths

 

? Localised PVNS

 

Epidemiology

 

2nd most common tumour of the hand

 

Age 40 - 60

 

Aetiology

 

Unknown origin

- theorized to be localized form PVNS

- similar histology

- however, lacks the inflammatory component of PVS 

- is considered by most to be a benign neoplasm

- may be a reactive process to minor trauma

 

Clinical

 

Usually found near flexor tendons of hands & feet

- painless, firm and multi-lobulated mass

- usually on volar surface of finger

 

May present with

- lump

- loss of function

 

X-ray

 

Can cause bone invasion and remodelling

 

MRI

 

Low signal on T1 and T2 and arising from the flexor sheath differentiates from sarcoma

 

Pathology

 

Gross

 

Arise from synovial tissue

1. Well-circumscribed & discrete

2. Nodular & encapsulated

 

Doesn't invade surrounding tissues

 

Diagnostic colour

- yellow (cholesterol)

- brown (haemosiderin)

- grey (fibrous tissue)

 

Histology

 

Giant cell tumours prominent

- hyalinised CT

- sheets of round, oval & spindle cells

- focal collections of foam cells - xanthoma cells

- scattered haemosiderin

 

Management

 

Marginal excision + bone currettage

 

Recurrence rate

- 10% - 20%

- to due to incomplete excision or spillage

- higher with bony involvement

 

 

 

 

 

 

 

Glomus Tumour

Epidemiology

 

Rare

 

Pathology

 

Hypertrophied glomus 

- coiled AV structure involved in temperature regulation

- > 50% in subungual region

- hand is the most common site

- usually under the nail plate

 

Symptoms

 

Triad

- pain

- exquisite tenderness

- cold intolerance

 

Examination

 

Ridging of nail bed

Blue spot at base of nail

 

X-ray

 

Well defined radiolucent eccentric lesion

- base of P3

- < 1cm

 

MRI

 

Dark on T1 / Bright on T2

 

Treatment

 

Remove nail plate

Longitudinal incision in nail bed

Excise tumour and repair nail bed

Replace nail

 

Lipoma

Epidemiology

 

F>M

 

3rd - 6th decade

 

Site

 

More frequent proximal

 

Most frequent

- thenar eminence 

- proximal phalanx

 

Findings

 

Non tender, mobile, soft

 

Does not transilluminate

 

Investigations

 

Radiolucent on X ray

- Bufolini's sign

 

Surgery

 

Negligible recurrence rate

 

Other Hand Tumours

1.  Foreign Body Granuloma

 

Management

 

Curettage and bone graft (if bony)

Excision of lump 

- recurrence very unusual

 

2.  Osteochondroma

 

Xray

 

Cortical flow evident

 

3.  Brown's tumour

 

Causes

 

Primary hyperparathyroidism

Secondary hyperparathyroidism

- CRF

 

X-ray

 

Lytic lesion

- often seen in distal phalanx

 

4.  Nora's lesion

 

Bizarre parosteal osteochondroma

 

5.  Neurofibroma

 

Not possible to dissect free

- need to excise

- end to end anastomoses

 

6.  Synovial Chondromatosis

 

Diffuse swelling

 

May have calcification

 

7.  Juvenile Aponeurotic Fibroma

 

Benign fibrous tumour 

- occurs in the hands of children and young adults

- no gender predeliction 

- no tendency to involve ulnar digits as with Dupuytren's disease

 

Calcification is distinguishing feature

- locally infiltrative

 

Management

 

Requires wide local excision without sacrifice of function

- local recurrence common

 

Metastatic fibrosarcoma after local recurrence of JAF reported

- careful follow up required

 

8.  Recurring Digital Fibrous Tumor of Childhood

 

Benign fibrous tumour that develops in fingers and toes in infants and children

- distinguished histologically by intracytoplasmic inclusion bodies within proliferating fibroblasts

 

Probable viral aetiology

- usually on several digits and intradermal

- recurrence rate up to 60%

 

Marginal excision if function compromised

 

No malignant potential 

- spontaneous regression described

 

9.  Malignant Tumours

 

Metastasis

- very rare 

- 50% lung cancer

 

Chondrosarcoma

- most common 

- chemo and radio insensitive

- only treatment is surgery

 

Osteosarcoma and Ewings

- quite rare

 

Dermatofibrosarcoma / Epitheloid Sarcoma / Synovial Sarcoma

 

Sarcoma Hand0001Sarcoma Hand0001

 

Schwannoma

Definition

 

Benign tumour of Schwann cells

 

Symptoms

 

May have a positive Tinel's

 

Pathology

 

Eccentrically located in nerve

- fascicles are splayed over it

 

Isolated

- Malignant degeneration rare

 

Part of NF syndrome

- malignant degeneration may be as high as 15%

 

Management

 

Surgical excision using microscope

- dissect fascicles off Schwannoma

 

 

 

Vascular Malformation

Symptoms

 

Dull ache and heaviness

- when arm dependent

 

Management

 

Non operative

 

Compression garments

 

Operative

 

Nil recurrence with complete excisions

 

Not always possible

- multiple debulking +/- amputation

 

 

 

Nerves

Anomalous Innervations

1.  Richie-comeau

 

Site

- ulna to median in palm

- provides motor to the thenar muscles

- ulna dominate hand

- may be due to RC anastomosis

 

Clinical significance

- carpal tunnel syndrome with no thenar atrophy

 

2.  Martin-Gruber 

 

Site

- median to ulna in forearm

- provides motor function to hypothenar eminence

 

Clinical significance

- cubital tunnel syndrome with no hypothenar atropy

- may be due to MG anastomosis

 

 

 

Brachial Plexus

Anatomy

Composition

 

C5 - T1

- prefixed: C4 (more common)

- post fixed: T2

 

Roots (3 Branches / LSD)(Interscalene)

Trunks (1 Branch)(Posterior Triangle)

Division (Clavicle)

Cords (5,5,3)(Axillary Artery)

 

Nerve roots

 

Formed by ventral and dorsal nerve rootlets

- in foramen

- DRG has cell bodies of sensory nerves

- rupture proximal to DRG indicates preganglionic

 

Run between scalenius anterior and medius

 

Branches

- long thoracic nerve (C5/6/7)(serratus anterior)

- nerve to subclavius (C5/6)

- dorsal scapula nerve (C5)(rhomboids)

 

T1 sympathetic ganglion close to T1 nerve root

- frequently injured together

 

Trunks

 

A.  Upper 

- C 5/6

- merger is Erb's point

- where SSN exits

- injury: SSN, axillary, MCN (lose SS, IS, deltoid, biceps)

 

B.  Middle

- C7

 

C.  Lower

- C8/T1

 

Branches

- suprascapular nerve (C5,6) from upper trunk

 

Divisions

 

Trunks divide into anterior and posterior

- behind clavicle

 

Cords

 

A.  Posterior cord (5)

- all three posterior divisions

- C5 - T1

- posterior to axillary artery

 

Branches

- radial is terminal branch

- axillary

- upper and lower subscapular

- thoracodorsal

 

B.  Lateral cord (3)

- anterior divisions of upper and middle trunk

- C5/6/7

- lateral to axillary artery

 

Branches

- MCN lateral to artery

- lateral branch of median nerve / runs across artery

- lateral pectoral

 

C.  Medial cord (5)

- anterior division of lower trunk

- C8 / T1

- medial to axillary artery

 

Branches

- medial median

- medial pectoral

- MCNA, MCNFA (medial cutaneous nerve of arm and forearm)

- ulna nerve is terminal branch (runs medial to artery)

 

Sensation

 

Roots / ASIA

 

Peripheral nerves

 

Supraclavicular region  C4

 

Regimental patch C5

- axillary nerve

 

Radial forearm C6

- LCNFA / MCN

 

Dorsal first web space C6

- radial nerve

 

Thumb and thenar eminence C6

- median nerve

 

Middle finger C7

- median nerve

 

Little finger C8

- ulnar nerve

 

Ulnar forearm T1

- MCNFA

 

Medial arm T2

- MCNA

 

Motor

 

Nerve roots / ASIA

 

C5 / deltoid / bicep

C6 / wrist extensors

C7 / tricep

C8 / MF FDP

T1 / interossei

 

Adjacent nerves

 

Trapezius (CN Xl)

- patient shrugs shoulders against resistance

 

Branches from roots

 

Rhomboid (C5)

- dorsal scapular nerve

- patient retracts scapula

- examiner uses hand to palpate

 

Serratus anterior (C567)

- long thoracic nerve

 

A.  Patient pushes against wall

- observe for winging

- patient protracts shoulder against resistance 

 

B. Some pateints won't be able to get arm up to wall

- raise arm for them

- get them to push arm away

 

Branches from the trunks

 

Supraspinatus (C5)

- suprascapular neve

- patient tries to initiate abduction of the arm from the side

 

Infraspinatus (C5)

- suprascapular nerve

- patient tries to externally rotate shoulder with arm by side

 

Branches of the posterior cord (C5-T1)

 

Deltoid (C5)

- axillary nerve

- patient abducts arm against resistance

 

Latissimus Dorsi (C7)

- thoracodorsal nerve

- patient adducts horizonal arm against resistance

 

Subscapularis

- upper and lower subscapular

 

Radial nerve

 

1.  Triceps (C78)

- patient extends elbow against resistance

 

2.  Brachioradialis (C6)

- patient flexes the elbow with forearm pronated

 

3.  ECRL (C67)

- radial nerve

- extend IF against resistance

 

4.  ECRB (C67)

- PIN

- extend MF

 

5. Wrist extension (C67-ECR, C67-ECU)

- radial and posterior interosseous nerve

- patient extends wrist

 

5.  Supinator (C6)

- patient supinates forearm in extension

 

6.  EDC (C8)

- PIN

- patient extends MCPJ

 

7.  ECU (C67)

- PIN

- extend wrist

 

8.  Extensor pollicis longus (C7)

- PIN

- patient extends thumb IPJ against resistance

 

Branches of the lateral cord (C5,6,7)

 

Pectoralis major (clavicular fibres) (C6)

- lateral pectoral nerve

- patient pushes arm forwards with arm horizontal

 

Biceps (C56)

- musculocutaneous nerve

- patient tries to flex elbow with forearm supinated

 

Lateral median nerve

 

1.  PT (C6)

- pronate in flexion

 

2.  FCR (C6)

- wrist extension

 

Branches of the medial cord (C8 / T1)

 

Pectoralis major (sternocostal fibres) (C7,8)

- medial pectoral nerve

- patient places hand on hip and pushes in

 

Medial branch median nerve

 

Flexor digitorum profundus (C8)

- AIN

- patient makes fist and resists extension of index finger

 

Flexor pollicis longus (C8)

- AIN

- patient flexes distal phalanx of thumb against resistance

 

Abductor pollicis brevis (TI)

- patient abducts thumb at right angles to palm against resistance

 

Ulna nerve

 

Flexor carpi ulnaris (C8)

- patient flexes wrist against resistance

 

Flexor digitorum profundus (C8)

- patient makes fist and resists extension of little finger

 

Interossei (TI)

 

 

Examination

Diagnostic Issues

 

Supraclavicular

- nerve root patterns of sensation and motor disturbance

 

Infraclavicular

- peripheral nerve root pattern / cord

 

Supraclavicular preganglionic

- dorsal scapular / long thoracic / suprascapular nerves injured

- Horner's

- lack of sensation supraclavicular

- no tinel's

 

Supraclavicular postganglionic

- + Tinels

- tender posterior triangle

 

Look

 

Aids

 

Front

 

Horner's 

- suggests C8/T1 root avulsion

 

Posterior triangle swelling / bruising

 

Wasting deltoid / biceps / Pecs

 

Wrist drop

 

Side

 

Hand on head

- axillary scars

 

Back

 

Trapezius

Deltoid

Supraspinatus/ Infraspinatus

Static winging

 

Feel

 

Palpate post triangle

- tenderness

- supraclavicular post ganglionic

 

Tinel's in post triangle

- supraclavicular post ganglionic

 

Sensation

 

Ask patient about sensory loss

 

Supraclavicular C4 

- suggests preganglionic injury

 

Axillary nerve C5 

 

LCNF C6 musculocutaneous

 

SRN C6 (1st dorsal webspace) 

 

C6 median n (thumb)

 

C7 median n (MF)

 

C8 ulnar n (LF)

 

C8 MCNF m cord (med forearm)

 

T1 MCNA m cord

 

T2 ICBN

 

Motor

 

Trapezius 

- function of accessory nerve important

 

Roots / From Behind

 

Rhomboids

- shoulders back

- DSN C5

 

Rhomboid Testing

 

Serratus anterior

- push shoulder forward

- LTN C5-7

 

Suggest preganglionic

 

Trunk

 

Suprascapular Nerve (C5)

- supraspinatous

- infraspinatous

 

Front / Nerve Root innervation

 

Deltoid 

- C5

- axillary / posterior cord

 

Bicep

- C5

- musculocutaneous / lateral cord

 

Left biceps wasting

 

Tricep

- C7

- radial / posterior cord

 

Wrist extension

- C6

- radial / posterior cord

 

Finger flexion

- C8

- median / medial and lateral cord

 

Finger abduction

- T1

- ulna nerve / medial cord

 

Decide if fits root pattern

- Otherwise consider cord injury

 

Cords

 

Post Cord

- axillary nerve (deltoid + T minor)

- radial nerve

- subscapularis

- lat dorsi TDN C7 (hand on hip or cough)

 

Medial Cord

- medial median (FDP, FPL, AbPB)

- medial pectoral (sternal head)

- ulna nerve (interossei, LOAF)

- MCNA / MCNFA (decreased sensation medially)

 

Lateral Cord

- lateral median (FCR, PT)

- musculocutaneous (biceps, sensation lateral forearm)

- lateral pectoral (clavicular head)

 

Reflexes

 

Biceps C5

Triceps C7

BR C6

 

4Cs

 

Cephalad joint - Neck

Concealed - axilla

Circulation

Collagen

 

Injury

Classification Leffert "OCRO"

 

I Open

 

II Closed

 

A  Supraclavicular 

- Preganglionic / Avulsion of Roots

- Postganglionic / Rupture of Trunks

 

B Infraclavicular

- cords & branches

 

C.  Post anaesthetic

 

III Radiation / Other

 

Tumour

Iatrogenic e.g. patient positioning

Other

 

IV Obstetric

 

A Erb C5/6

B Klumpke C7/8 T1

C Mixed

 

Narakas Rule of 7's

 

70% MVA

70% of these MBA

70% associated injuries

70% supraclavicular

70% root avulsions 

70% C8/T1 involvement

70% persistent pain

 

Aetiology

 

MBA most common

 

Gunshot Injury

- deficit 2° nerve concussion

- usually improves

- observe for 3 /12

- explore if no improvement / large residual deficit

 

Position of arm

- abducted above horizontal (lower lesion)

- abducted below horizontal (upper lesion)

 

Associated Injuries

 

Axillary / subclavian artery 10-20%

 

Fracture humerus / clavicle / scapula / ribs

 

Dislocations GH / AC / SC joints

 

Rotator cuff tears

 

Patterns

 

Supraclavicular preganglionic (nerve root patterns)

Supraclavicular postganglionic (trunks)

Infraclavicular (cords)

 

Can be mixed

- 2 patterns can occur in one nerve root

 

Supraclavicular Preganglionic / Root avulsion

 

Clinical

 

Severe pain in anaesthetised arm

- starts day 1 in 50%

- constant burning + superimposed `lightning shocks`down limb

 

Tender & swollen in posterior triangle

- pseudomeningocoeles

 

Tinel's negative

- dorsal root ganglion intact so no wallerian degeneration of sensory nerve

 

Horner's if T1

 

Evidence of injury to branches from roots

- long thoracic / serratus anterior

- dorsal scapular / rhomboids

 

Investigations

 

NCS

- SNAP normal (as fibres in continuity with DRG)

- abnormal sensation

 

EMG

- denervation dorsal neck muscles (posterior rami)

 

Diaphram paralysis

- high nerve root lesion / phrenic nerve

 

MRI Neck

- pseudomeningocoeles

- empty root sleeves

 

Patterns

 

1.  Erb's Palsy

 

C5 & 6 +/- 7

- also lose branches from roots and trunk

- long thoracic / dorsal scapular / suprascapular

 

Clinical

- shoulder adducted & internally rotated

- elbow extended

- forearm pronated 

- waiter's tip

 

Brachial Plexus Erbs

 

Paralysis of 

- deltoid / abductors

- SS / abductor

- IS / external rotator

- biceps / supinator and elbow flexor

 

Sensory loss

- lateral shoulder

- lateral forearm and hand

 

2.  Klumpke's palsy

 

C8 & T1 lesion

- paralysis intrinsics, wrist and finger flexors

- sensory changes medial hand and forearm

 

Klumpkes Hand 1Klumpkes Hand 2Klumpes Forearm

 

Horner's 

- ptosis (drooped)

- miosis (small)

- anhidrosis (dry)

- enophthalmos (sunken)

 

Supraclavicular Postganglionic (trunks)

 

Diagnosis

 

Tinel's positive

 

SSN / DSN / LTN intact

 

No Horners

 

Patterns

 

Erb's Palsy

 

Klumpke's Palsy

- no Horner's

 

Infraclavicular

 

Peripheral nerve patterns

 

A.  Lateral cord weak (C5,6,7)

 

MCN

- biceps (C5)

 

Lateral cord median

- FCR (C6)

- PT (C6)

 

Lateral pectoral nerve

- clavicular head

 

B.  Posterior cord weak (C5-T1)

 

AXN (C5)

- deltoid

 

Radial nerve

- triceps (C7)

- ECRL / ECRB (C8)

- EDC (C8)

- EPL (C8)

 

Upper and lower SCN (C5,6)

- SSC, T major

 

LTN (C5,6,7)

- latissimus dorsi

 

C. Medial cord weak

 

Ulna nerve (C7,8 T1)

- FCU (C8)

- LF FDP (C8)

- interossei (T1)

 

Medial median Nnerve

- FDP IF / MF

- FPL

- Thenar / APb

 

Medial pectoral

- sternocostal P. major

 

X-rays

 

CXR

- elevated diaphragm (phrenic nerve injury)

- fractured 1st rib

- suggests root avulsion

 

C spine Xray

- avulsion of C7 TP 

- suggests root avulsion

 

Shoulder Xray

- fracture clavicle / Scapula / GHJ / ACJ / SC

 

NCS / EMG

 

Takes 3 weeks for Wallerian degeneration / denervation to occur

 

EMG

- muscle sample of specific groups of interest

- denervation / sharp waves & fibrillation potentials

- re-innervation / polyphasic AP on volitional activity

 

Preganglionic lesion

 

NCS

- Skin Anaesthetic 

- SNAP persist because of DRG

 

EMG Denervation in

- paravertebral muscles

- serratus anterior

- rhomboids

 

Postganglionic lesion

 

NCS

- skin anaesthetic

- no SNAP as due to wallerian degeneration

 

MRI

 

MRI C Spine

 

Nerve root avulsion

- displacement or oedema spinal cord

- empty foramen

- pseudomeningocoeles (takes 5 days to develop)

 

MRI Shoulder

 

Difficult to correctly image trunks and cords

- high amount of oedema / hard to define severity of injury

 

Hems et al J Hand Surg Br 1999

- some usefulness in identifying level of injury in postganglionic

 

Prognosis 

 

1.  Infraclavicular > Supraclavicular

 

2.  Upper trunk > Lower trunk

 

3.  Better in children and young adults

 

 

 

Management

Goals

 

1.  Shoulder abduction and ER

2.  Elbow flexion

3.  Wrist extension

4.  Median nerve / C67 / lateral cord sensation

5.  Finger flexion

 

Options

 

1.  Nerve repair / neurorrhaphy

2.  Neurolysis

3.  Nerve graft

4.  Nerve transfer / neurotisation

5.  Tendon / muscle transfer

 

Open injury / laceration

 

Immediate surgery

- can tag ends and return later

- primary repair / nerve graft

 

GSW

- can continue to improve over time

- blast injury to plexus

 

Surgical Approaches

 

Supraclavicular

 

Z incision

- longitudinal along posterior border SCM

- transverse along inferior clavicle

- longitudinal in deltopectoral groove

 

Supraclavicular approach

- posterior triangle

- SCM / omo-hyoid / clavicle / trapezius

 

Superficial dissection

- subcutaneous Tissue

- platysma

- elevate clavicular head of SCM

 

Deep dissection

- may need to divide omo-hyoid

- identify scalenius anterior and medius

- ligate external jugular vein

- suprascapular and transverse cervical arteries

 

Uses

- identify nerve roots / nerve stimulation

- nerve graft C5, C6, C7

- phrenic or accessory to SSN

 

Infraclavicular

 

Deltopectoral approach

- P. major tendon divided

- P. minor reflected from coracoid (leave stump to repair)

 

Uses

- nerve stimulate medial pectoral nerve

- if working transfer to MCN

- or ICN / Oberlin

 

Pre ganglionic lesion / Nerve root avulsions

 

Options

- spinal cord level nerve root reimplantation

- nerve transfers

 

Spinal Cord Level Nerve Root Reimplanation

 

Results

 

Carlsted et al Neurosurgical Focus 2004

- reimplanation of nerve root avulsion in 9 year old boy

- C5 - T1

- regained motor function in arm and hand use

 

Carlsted et al J Neurosurg 2000

- nerve reimplantation in 10 patients

- surgery from 10 days to 9 months

- 3/10 recovered MRC grade 3 power

- better with higher lesions and earlier reimplantation

 

Shoulder Nerve Transfers

 

A.  Accessory nerve to SSN

 

Technique

- test trapezius

- surgery performed in the posterior triangle

 

Suzuki et al J Reconstruct Microsurg 2007

- accessory nerve to SSN in 12 patients

- average shoulder flexion 70o

- average shoulder abduction 77o

 

B.  Consider ICN to axillary nerve

 

Biceps Nerve Transfers

 

Connect to motor unit MCN

 

A.  Medial pectoral nerve to MCN

 

Issue

- much simpler than ICN

- often not intact

- test with nerve stimulator

 

B.   ICN to MCN

 

Issue

- problem is disparity in axon number

- T3-6 in males

- T3,4,7,9 in females to avoid breast denervation

 

Merrell et al J Hand Surg Am 2001

- 90% achieved MRC grade 3 power

- 70% grade 4 power

 

C.  Motor branch ulna nerve to MCN / Oberlin transfer

 

Technique

- use nerve stimulator

- isolate motor branch to FCU, preserving intrinsics

 

Sensation median nerve

 

ICN to lateral median

 

Hatori et al Plast Reconstr Surg 2009

- 17 patients

- none recovered 2 point discrimination

- 13 had perception of cold, 8 had perception of head

 

Post ganglionic lesion

 

Timing

 

A.  Late / 3 months

- evaluate recovery on EMG

- look for renervation potentials

 

B.  Immediate repair

 

Options

- neurolysis

- nerve repair

- nerve grafting

 

Neurolysis

 

Indication

- nerve functioning with nerve stimulator

- release nerve

 

Nerve repair 

 

Indication

- ruptured

- able to perform tensionless repair

 

Nerve graft

 

Indication

- non functioning on nerve stimulator

- long segment of clearly severely damaged nerve

- rupture unable to be repaired primarily

 

Graft Options

- sural nerve (30cm)

- saphenous

- MCNFA

 

Options

- C5 to SSN for shoulder abduction

- C5 to posterior division upper trunk (axillary)

- C6 to anterior division upper trunk for elbow flexion

- C7 to posterior division middle trunk (wrist and elbow extension)

 

Late salvage

 

Options

- shoulder fusion

- elbow flexion / tendon transfers

- wrist fusion

- amputation

 

Shoulder fusion

 

Need functioning serratus anterior and trapezius

- for scapula control

 

Elbow Flexion

 

1.  Lat Dorsi transfer

- entire muscle mobilised on NV pedicle

- attached proximally & distally to replace biceps

 

2.  Triceps to Biceps transfer

 

3.  Steindler flexorplasty

- transfer of CFO to more proximally on anterior humerus

- need power of wrist flexors

- will often get some pronation deformity

- also need wrist extensors to prevent excessive wrist flexion

 

4.  Clark Pectoralis major transfer

- transfer of sternocostal P. major

 

5. Free Gracilis transfer

- innervated by ICN

 

Wrist arthrodesis

 

Mid humeral amputation

 

Indications

- flail limb

- limb is a hazard

 

Shouldn't be performed for pain relief

 

 

 

Nerve Conduction Studies / EMG

Pathological Processes

 

Two possible types of injury

1.  Axonal

2.  Myelin sheath

 

Myelin Sheath Damage

 

Causes

 

Commonly seen in compression

- i.e. CTD, ulna nerve at elbow

- area of focal demyelination

 

Can progress to a conduction block

- some or all axons simply stop working

- decreases the amplitudes

 

Effect

 

1.  Usually affects sensory fibres first

- affects motor fibres later

 

2.  Results in slowing of conduction velocity

 

3.  Prolonged distal latency

- i.e. long time for stimulation to reach recording electrodes

 

4.  Effect is focal

- slowed conduction velocity above block

- normal below

- can isolate level of entrapment

 

5.  If progresses to conduction block

- decreased amplitude

 

Axonal Damage

 

Cause

 

Due to severe damage to the axon

- laceration / avulsion / severe contusion i.e. Sunderland type 3 and 4

 

Effect

 

1.  Decreased amplitude - related to number of axons affected

2.  Normal latency and conduction velocity

3.  In contrast to demyelination, cannot get normal result by stimulating below level of lesion

 

SNAP

 

Definition

 

Sensory nerve action potentials

 

Technique

 

Stimulate a sensory nerve and measure the action potential distally

 

Median nerve

- two stimulations over median nerve in forearm (S)

- ring type recording (R) electrodes on index and middle finger (sensory nerves only)

 

Ulna nerve

- stimulation over ulna nerve at elbow or wrist

- record over little finger

 

Measure

 

Latency

- time to reach distal electrodes

 

Conduction velocity

- simply measure distance between electrodes

- computer calculates velocity

 

Amplitude

- number of axons being stimulated

- also need all the axons transmitting at a similar velocity or get a wide, shorter velocity

 

NCS Sensory

 

Uses

 

Diagnosis of carpal tunnel syndrome

- measure conduction velocity

- in upper limb is usually > 50 m/s

- compare to ulna nerve / standard charts

- median nerve is slower than ulna, but difference should be < 0.2 ms

- usually use 0.3 ms as cut off

 

Ulna nerve compression

 

CPN compression

 

Radial nerve

 

Sciatic nerve

 

CMAP

 

Definition

 

Combined motor action potential

- called this because is difficult to stimulate just one muscle

- i.e. on thenar eminence want to stimulate just APB, but would get FPB also

 

Technique

 

Stimulate a nerve and record from a muscle that it innervates

 

Measure

 

1.  Distal latency

 

2.  Conduction velocity

- stimulate at 2 points and measure difference between times

- 50 m/s UL

- 40 m/s LL

 

3.  Amplitude

 

NCS Motor

 

Uses

 

Same as for SNAP

- entrapments

- slowing of conduction velocity and latency with demyelination

- +/- decreased amplitude if any axonal damage (severe entrapment, traumatic contusions, lacerations)

 

MNAP

 

Principle

Combine sensory and motor

- measuring electrodes simply in palm in median nerve distribution

- measure sensory and motor components

- see in delayed latency or conduction velocity

- very simple for CTD

- can move onto more specific SNAP and CMAP if needed

 

Responses

 

Amplitude

 

Proportional to number of functional axons

- loss of axons causes decrease in response amplitude

- amplitude is a measure of the total number of functioning axons in the nerve

 

Conduction Velocity

 

Calculated fro

m the latency values

- reflects only the function of the fastest conducting fibres

- fortunately most compressive or traumatic disorders affect the largest fibres

 

Calculated by

- dividing the latency by the distance between the stimulating and recording electrodes

 

Problem in CMAP

- the response is measured over the muscle

- the delay at the motor end plate must be considered

- conduction slowed by the small, unmyelinated terminal branches of the motor axon

- and by the time taken for release of Ach

- typically ~1 mS

- because the delay is fairly constant the terminal latency can be compared with the range of normal values

 

The Late Responses

 

Uses

 

Nerve root or proximal nerve lesions 

- cannot use simple NCS

- stimulate a peripheral nerve and recording over a muscle

- wait for a delayed signal

-  has travelled up the nerve to the anterior horn cell then returned to the muscle

 

F Response

 

Technique

 

Supramaximal stimulus is applied to a nerve

- motor nerves are directly depolarised

- like all axons they conduct equally well in all directions

 

2 impulses

Orthodromic 

- which travels to the muscle and produces the typical M response

 

Antidromic 

- which travels back to the anterior horn cell and depolarizes the cell body

- to be detected, the second muscle contraction has to occur after the first has subsided

- only muscles in which the round trip takes over 15 - 20 mS can be used

 

Problem

 

Does not measure sensory nerves

 

Uses

 

Brachial plexus injury

- want to know if nerve roots intact

- look in muscles relevant for each nerve root

- i.e. stimulate median nerve, look in thenar eminence (T1)

- look to see if F wave intact, delayed or absent

- problem is most muscles supplied by more than one nerve root

 

Now

- use MRI to see if nerve root avulsion

 

H Reflex

 

This is the electrical equivalent of the deep tendon reflex

A mixed peripheral nerve is sub maximally stimulated

- stimulates the large myelinated sensory nerves that convey muscle stretch

- they are the most easily depolarised of the axons

- following a relatively weak stimulus these sensory fibres are selectively depolarised

- a signal ascends to the dorsal root ganglion and then through the monosynaptic reflex arc

- depolarises the anterior horn cells 

- causes a secondary signal in the motor axons with a subsequent muscle contraction

 

Characterised by having a consistent latency 

- is elicited by a stimulus so small that it does not cause a direct muscle contraction.

 

Unfortunately it can only be elicited in the tibial nerve (and recorded over the gastrocnemius)

 

Electromyography (EMG)

 

Technique

 

Needle placed in relevant muscle

- record electrical potential

- at rest and voluntary contraction

 

NCS Motor

 

NCS Waveform

 

Neuropathy

 

Denervation

- takes 3/52 to see

- amount of time for wallerian degeneration to occur

- if do earlier will get a false negative

- normal muscle electrically silent at rest

 

Findings

- spontaneous depolarisation in muscle

- fibrillations

- positive sharp waves

 

Reinnervation

- takes 3/12 to see

- due to surviving motor axons branching out and recruiting other motor units

 

Findings

- see large polyphasic motor unit potentials

 

Myopathy

 

Muscle problems

- specific patterns of EMG
- Duchenne's muscular dystrophy /myotonica dystrophy

 

Shortfalls of EMG

 

It is only a sampling technique

- normal areas in an abnormal muscle may have normal potentials

 

Specific uses of NCS / EMG

 

Conduction blocks

 

SNAP / CMAP

- median nerve, ulna nerve

- confirm entrapment

- evaluate site of entrapment

 

Axonal / Nerve damage

 

1.  Radial nerve palsy with humeral fractures 

 

Question

- is nerve in continuum or lacerated?

 

NCS / EMG cannot tell you that

- similar findings for Stage 4 and 5 Sunderland

 

Can give information regarding severity of injury

- denervation potentials at 3/52

- indicates Sunderland grade 3 or greater

 

Can give idea of prognosis

- i.e. is there any chance of recovery?

- reinnervation on EMG at 3/12

 

2.  CPN injury at knee, sciatic nerve injury following THR

 

Can give you idea of prognosis

- i.e. SNAP intact at 3/12

- neuropraxia

 

Neuropraxia

 

Minimal axonal damage

- demyelinating / conduction block only

- no Wallerian degeneration

 

Findings

 

3/52

- some SNAP and CMAP still seen

- minimal denervation signs i.e. fibrillation

- means nerve is not too badly injured

- prognosis good

- should be just a neuropraxia

 

Laceration / Neurotmesis

 

Both conditions will lead to Wallerian degeneration

- severity dependant on number of axons injured

 

3/52

- no SNAP / CMAP

- may be reduced or no amplitudes depending on number of axons injured

- see fibrillations in muscle in EMG due to denervation

 

3/12

- looking for reinnervation

- hoping to see large polyphasic AP due to surviving motor axons branching out and recruiting

- if this is not seen, is a poor sign as means no surviving axons

- can repeat later hoping some axons have sprouted down intact tube

 

Problems with NCS

 

1.  Obese patient

2.  Oedema

3.  Electrical inteference

- 50 MHz from fluorescent lights

- need to do in Faraday room

- difficult to do in ICU

4.  Must remove oils / moisturiser

5.  Sweat

 

Spinal Cord Monitoring

 

Used to assess spinal cord integrity during spinal instrumentation

 

Technique

 

Posterior tibial nerve stimulated

- scalp SEP used to monitor for surgical induced changes

- signal monitored is in the posterior column

- relatively immune to compromise of the anterior spinal artery

- motor control is located anteriorly in the descending corticospinal tracts

 

 

Nerve Entrapment

Median Nerve

Anatomy Median Nerve

 

Formation

- medial and lateral branches median nerve

- from medial and lateral cords respectively

- C5 - T1

- median branch crosses artery, such that median nerve lies lateral to artery

- no branches in arm

- medial nerve crosses brachial artery to lie medial to it

 

Elbow

- nerve medial to artery at elbow

- passes under bicipital aponeurosis then between heads of pronator teres

(sublime tubercle and CFO)

- medial nerve supplies PT, FCR, PL, FDS 

 

AIN 

- arises as pass between two heads PT from the dorsal aspect of median nerve

- occasionally passes deep to deep head of PT

- passes beneath arch of FDS

- runs distally along intra-oseous membrane between FDP & FPL

- branch to FDP / FPL ~ 4 cm distal to origin then branch to PQ

 

Median nerve 

- runs under arch of FDS to run on FDP

- crosses the ulna artery  

- at wrist it is lateral to FDS tendons, medial to FCR with PL above

- palmar cutaneous branch emerges on radial side of PL to run over TCL

 

Branches

 

1.  Motor recurrent 

- usually arises laterally

- sometimes comes off medial side and runs over distal edge of TCL (danger during endoscopic CTD)

- can pass through TCL

 

2.  Medial sensory branch

- gives two common digital nerves

- motor to first 2 lumbricals

 

3.  Lateral branch 

- supplies thumb and lateral index finger

 

 

 

Anterior Interosseous Nerve Palsy

Definition

 

Symptoms & signs due to compression of AIN

 

Sites of Compression

 

Fibrous

- Pronator Teres (most common)

- FDS arch

- Fascial bands 

- Bursa

 

Vascular

- thrombosis in leash vessels over AIN

 

Muscular

- aberrant belly FPL (Gantzer's)

- palmaris profundus

- aberrant FCR ulnar origin

- anomalous FDS origins

 

History

 

1.  Pain in proximal forearm

- vague pain

- most common symptom

 

2.  Motor deficiency

- FPL

- IF FDP

- PQ

 

3.  No sensory disturbance

 

Examination

 

Discomfort over site of compression

 

Inability to tip-to-tip pinch grip IF &Thumb

- weak pulp-to-pulp pinch possible

- Weak FPL / Index FDP / PQ

 

Provocation

- resisted pronation with elbow flexed 90o

 

Investigation

 

EMG FDP / FPL / PQ

 

DDx

 

Rupture FPL / FDP

Median N entrapment

C8 lesion

 

Management

 

Non operative Management

 

Avoid Aggravating Factors

RICE

NSAIDS

 

Operative Management

 

Technique

 

Release

- as per pronator syndrome

 

Results

 

Schantz et al J Hand Surg Br 1992

- 20 cases of AIN compression

- operated on 15 with 12 good results / 3 required tendon transfer

- non operative on 5 / 3 continued palsy at 4 years

- recommended operative release

 

 

Carpal Tunnel Syndrome

Definition

 

Symptoms & signs due to compression of median nerve in carpal tunnel

 

Epidemiology

 

Middle aged female

- F:M   2:1

- peak age 40-50 years

- often bilateral

 

Aetiology

 

Underlying process is decreased microvascular perfusion 

- normal press in CT is 2.5mmHg

- most CTS > 30 mmHg & > 90 mmHg with palmar flexion

 

Commonest cause in tenosynovitis

 

Anatomical

 

1. Decreased size

- bony abnormality / thickened TCL

 

2. Increased contents

- hypertrophic synovium / fracture callus / hematoma

- neuroma / lipoma

- abnormal muscle bellies / persistent median artery

 

Physiological

 

1. Neuropathic Conditions

- diabetes / alcoholism / proximal lesion of median nerve (Double Crush)

 

2. Inflammatory Conditions

- tenosynovitis / RA / infection / gout

 

3.  Altered fluid balance

- pregnancy / eclampsia / OCP

- thyroid problems / CRF / acromegaly / obesity

 

Patterns of Use

 

1.  Repetitive flexion / extension

- manual labour / typing

 

2.  Weight bearing with wrist extended

- paraplegia (weight bear on palms) / long-distance cycling

 

3.  Vibration

 

Anatomy

 

Transverse carpal ligament / TCL

- tuberosities of scaphoid and trapezium laterally

- pisiform and hook of hamate medially

- distal volar wrist crease proximal limit

- Kaplan's line (apex of interdigital fold between thumb and IF) distal limit

 

Carpal tunnel

- FCR in separate tunnel with FPL separate and below

- median nerve radial to 4 FDS

- IF / LF below MF / RF

- 4 FDP at base

- FPL separate 

 

MRI Wrist Carpal TunnelMRI Wrist Carpal Tunnel 2

 

Motor Branch of Median nerve

 

Most important structure at risk / location can vary

 

1. Extraligamentous Recurrent / 50%

- branches distal to TCL with recurrent course to thenar muscles

 

2. Subligamentous / 30%

- branches beneath TCL / lies close to median nerve

- recurrent course to thenar muscles distal to TCL

 

3. Transligamentous/ 20%

- branches beneath TCL and pierces TCL to enter thenar muscles

 

4. Other

- proximal division

- branch from ulnar border of median nerve

- nerve superficial to TCL

 

Palmar Cutaneous Branch of Median Nerve

- arises in distal 1/3 of forearm from palmar-radial side of median nerve

- usually 5 cm proximal to wrist

- Pierces deep fascia between FCR & PL

 

History

 

Often diverse 

 

Classic

- pain & numbness radial 3± digits

- nocturnal wakening with relief from shaking

- worse with driving

 

Examination

 

Look

- thenar wasting

 

Feel

- abnormal thenar sensation suggests higher compression

- decreased sensation lateral 3 1/2 digits

 

Move

- APB weakness

 

Augmented Phalen's 

- elbow extended & supinated

- wrist held flexed 60° 2 fingers for 30 seconds

- sensitive 80% / specific 99%

 

Tinel's

- percussion of the median nerve at wrist 

- paresthesia in distribution of median nerve indicate a positive test   

- sensitive 75% / specific 95%

 

DDx

 

EJ compression

- more proximal pain / AIN weakness

 

T1 lesion

- check interossei power

 

C6/7 lesion 

- similar sensory loss

- check wrist extension / triceps

 

NCS

 

SNAP

 

Stimulate proximally

- measure in IF and MF (sensory only from median)

- measure latency / conduction velocity / amplitude

 

Conduction velocity

- compare to ulna nerve

- usually > 50 m/s

- median nerve slightly slower

- should be within 0.2 / 0.3 m/s

- can compare to tables or to contralateral median nerve (may be bilateral pathology)

 

Latency

- > 3.5 ms = Abnormal

- > 1 ms between sides

 

Results

 

90% sensitive

 

10% false negative rate

- intact conduction in a small number of fibres will give normal conduction velocity for whole nerve

- normal study does not rule out CTS

 

EMG

 

Denervation activity (late change)

- spontaneous depolarisation

- fibrillations

 

Re-innervation

- large polyphasic AP

 

X-ray

 

Exclude wrist arthritis / tumour

 

Management

 

Non-operative management

 

Options

 

Splint

 

Wrist in neutral / Night splints

 

NSAID

 

HCLA

 

Risk

- must avoid intraneural injection

- can cause chronic pain and disability

 

Pregnancy

 

Incidence

- 2%

- most recover 6/52 after delivery

- very rarely require decompression

 

Management

- splints

- HCLA

 

Operative Management

 

Indications

 

Failure non operative management

Permanent numbness / weakness

- indicates nerve damage which may not resolve

 

Options

 

Open carpal tunnel release

Endoscopic carpal tunnel release

Neurolysis

 

Open Carpal Tunnel Release 

 

Effect

 

1.  Increase volume carpal tunnel by 25% 

 

2.  Increases Guyon's canal

- may relieve compression ulna nerve / LF numbness

- Guyon's canal goes from triangular to circular

 

Technique

 

LA infiltration over site of release

- incision in line with radial side ring finger

- parallel to and ulna side of thenar crease

- if cross wrist, ulna side of PL to avoid palmar branch of median nerve

- divide palmar aponeurosis which has longitudinal fibres

- divide TCL which has transverse fibres

- ensure released proximally and distally

- inspect for ganglion etc

 

Endoscopic CTR

 

Issues

- transection of recurrent branch median nerve

- especially with abnormal anatomy and inexperienced surgeons

 

Technique

 

GA, Tourniquet

 

Proximal transverse incision at wrist crease

- insert spatula

- under TCL, feel it, clear soft tissue

- insert cannula

- exits in palm through distal incision

- wrist DF over bump with strap

 

Insert camera looking up at TCL

- must see transverse fibres in full for entire length

- clean with Q tip, or with probe if needed

- ensure nerve branches not crossing plane

- cut with hook knife under vision

 

Results

 

Trumble et al JBJS Am 2002

- RCT of 192 patients open v endoscopic

- better grip strength in first 3 months

- less scar tenderness and earlier return to work

- no complications from endoscopic technique

 

Complications

 

Incorrect diagnosis

 

Incomplete decompression

 

Division of palmar branch

 

Palm dysaesthesia with is difficult to salvage

- sensitivity often precludes use of hand

- avoid by always staying ulnar to thenar crease

 

Diagnosis

- confirmed by LA block

 

Management

- explore and bury nerve ending

 

Hypersensitive Scar

- much more common if cross wrist crease

 

"Pillar Pain" 

- 4% at 10 months post surgery

 

RSD

- decreased with minimal nerve trauma & avoiding neurolysis

 

Division of recurrent branch 

 

Management

- operative repair

 

Tenderness / sensitivity of median nerve

 

Cause

- due to superficial course post op

 

Management

- if a real problem needs soft tissue to cover

- proximally can use pronator quadratus

- distally use hypothenar fat graft on vascular pedicle

 

Flexor tendon bowstringing or adhesions

- Bowstring tendons 2% of open CTR

 

Persistant numbness

- may take 12 months for all symptoms to resolve

- loss of Schwann cells resulting in persistent conduction block

 

Recurrence

 

History

- symptom free interval

- usually due to scar

 

 

 

Pronator Syndrome

Definition

 

Forearm pain caused by compression of median nerve

 

Sites of Compression

 

Pronator Teres

- commonest site

- hypertrophied / excess fascia

 

Ligament of Struthers

- remnant third head Coracobrachialis

- runs from supracondylar spur to medial epicondyle

- median nerve & brachial artery may be deep to it

 

Bicipital Aponeurosis

- lacertus Fibrosis

- from medial border of biceps to subcutaneous ulna border

- may be thickened

 

Arch of FDS

- runs from humeroulnar Head (origin CFO & Sublime tubercle medial coronoid) 

- inserts anterior oblique line on radius

- accessory muscle slips and anomalous origins of FDS

 

History

 

Pain in anteromedial EJ / volar aspect of distal arm 

- worse with repetitive pronation / supination eg tennis, tools

 

May have

- intermittent / nocturnal parasthesia

- some weakness

 

Examination

 

Tenderness at site of compression

- proximal flexors

 

Pain with resisted pronation elbow in flexion / PT

 

Other provocations test

- Ligament of Struthers - resisted flexion of elbow at 135°

- Bicipital aponeurosis - resisted supination flexed elbow 

- Arch of FDS - resisted flexion of FDS of MF

 

NCS

 

Aim

- confirm location 

- exclude CTS

 

Findings

- delayed conduction velocity across elbow 30%

- EMG abnormalities of PT or FCR

 

X-ray

 

Spur

- seen with ligament of struthers

 

MRI

 

May help identify site of compression / ligament of struthers

 

Management

 

Non-operative Management

 

NSAIDS

Avoid aggravating activities

RICE

 

Operative Management

 

Technique

 

Medial incision

- divide bicipital aponeurosis

- release pronator teres

- release FDS

- +/- ligament of struthers if present

 

 

 

 

Radial Nerve

Pin Syndrome

Definition

 

Loss of PIN motor function with no pain

- multiple potential causes

- may be caused by compression as per radial tunnel

- may be post fracture or surgery

- may be caused by synovits / ganglion / rheumatoid nodules etc

 

Symptoms

 

Often heralded by deep aching pain in forearm that resolves

- is followed by PIN weakness

 

Most commonly is incomplete lesion

- weakness of extension of index and middle or just thumb

 

Examination

 

No sensory loss

 

Characteristic radial deviation with wrist extension

- BR & ECRL functioning

- supplied by radial nerve

 

NCS / EMG

 

Can be helpful

 

EMG of appropriate muscles

- demonstrates denervation

 

MRI

 

Looking for mass lesion

 

Site of Compression 

 

FREAS

 

Trauma - Monteggia fracture

Iatrogenic - surgery radial head / radius

Inflammation - RA nodule / synovitis of radio-capitellar joint DRUJ

Masses - lipoma / ganglia

 

Local injections

Lead poisoning - usually bilateral / motor palsy without sensory

Conversion reaction

Polyarteritis Nodosa

Muscle rupture

 

DDx

 

Locked trigger finger

Tendon rupture

 

Management

 

Non operative

 

Splint / therapy

- wait 3 months for recovery

 

Operative

 

Indications

- ganglion / rheumatoid nodule / synovitis

- failure to recover post operatively

 

Technique

 

Operative release

- posterior approach

- between EDC and ECRB

- divide supinator

 

PIN in radial tunnel release

 

 

Radial Nerve Anatomy

Originates

- terminal branch posterior cord / C5 - T1

- runs anterior to subscapularis / teres major / lat dorsi

- passes into triangular space (between humerus / long head of triceps / teres major)

- enters posterior compartment of arm

 

Arm

- runs in the radial groove between medial and lateral head of triceps, with profunda brachii

- gives a branch to the long and medial head of triceps (this branch runs with the ulna nerve) before the groove

- also gives the posterior cutaneous nerve of the arm

- in the groove branches to the lateral head  again to the medial head (this branch also supplies anconeus)

- also the lower lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm, which perforates the lateral head

 

Elbow

- passes anteriorly through intermuscular septum

- runs between BR / ECRL laterally and brachialis medially

- supplies these muscles and the elbow joint

- at the level of the lateral epicondyle, the radial nerve divides into superficial branch radial and PIN

 

Superficial branch

- runs under BR until it emerges between it and FCR

- runs superfical to first extensor compartment

- supplies dorsum of hand

 

Supinator

- has superficial and deep layers

- originates from the supinator crest of the ulna

- inserts onto the lateral surface of the radius between the anterior and posterior oblique lines

 

PIN

- passes through the radial tunnel which is between the radiohumeral joint and the distal extent of supinator

- passes under a fibrous band of ECRB

- under the radial recurrent leash of vessels

- into supinator (arcade of Frohse)

- then out from under another fibrous band of supinator

- runs over APL

- dips to run on the interosseous membrane

- ending as a small nodule which supplies the wrist joint

 

PIN then divides

- a superficial branch (supplies EDC, EDM, ECU)

- the deep branch supplies APL, EPB, EI and EPL

 

 

 

 

Radial Tunnel Syndrome

Definition

 

Dynamic structural compression syndrome of PIN

- causing pain with little or no muscular weakness

- similar presentation to lateral epicondylitis / pain more distal

 

Anatomy

 

Radial tunnel begins at radiohumeral joint

Extends to end of supinator muscle

 

Sites of compression

 

PIN can be compressed by FREAS in radial tunnel

 

Fibrous bands

- level of radio-capitellar joint

 

Recurrent leash of Henry 

- radial recurrent artery

- vessels to mobile wad

 

ECRB 

- nerve branches caught between ECRB and supinator

 

Arcade of Frohse 

- free fibrous proximal edge supinator (superficial belly)

- most common site of compression

- thought to be more tendinous in some patients (30 - 80%)

- thought to become more fibrous in some patients with repetitive supination

 

Supinator distal edge

- occasional cause

- always decompress to here

 

Clinical

 

Pain is similar to tennis elbow

- lateral elbow joint / CEO area often radiating to wrist

- deep ache or similar to muscle cramp

- often at night

- exacerbated by exercise 

- relieved by rest

 

Examination

 

Point tenderness 5cm distal to CEO 

- more proximal with Tennis Elbow

- Often tender in normal individual --> compare to other side

 

Provocation test

- Arcade of Frohse 

- resisted supination

 

NCS 

- unhelpful / usually normal

 

Local Anaesthetic block

 

Best test

- inject LA in most tender spot

- usually distal to CEO

- must produce PIN palsy to confirm diagnosis

- A prior negative injection to lateral condyle for tennis elbow

 

DDx

 

Tennis Elbow

- failure of HCLA lateral epicondyle to relieve pain

- can have both tennis elbow and radial tunnel syndrome

 

Radiocapitellar pathology

- OA / RA / OCD / Loose body

- no pain with supination / pronation

 

Radiculopathy 

 

NHx 

 

Tends to resolve spontaneously

 

Management

 

Non-Operative

 

RICE

Avoid provocative activities

Splint

 

Operative

 

Options

- anterior (can release all potential sites of compression)

- posterior (can only release supinator)

- brachioradialis muscle splitting

 

Anterior approach

 

Henry's approach

- start 4cm proximal to elbow joint

- identify nerve between BR & Brachialis & then follow distally

- release any proximal fibrous bands / divide recurrent vessels

- pronate / supinate and release ECRB if any compression

- fully pronate and divide all fibres of supinator

 

Posterolateral approach

 

Thompson's

- incision just distal to lateral condyle for 8cm

- dissection between ECRB & EDC

- identify supinator

- find PIN distally and follow proximally

 

Trans-brachial approach

 

Brachioradialis splitting

- direct approach to radial tunnel

- longitudinal incision 6cm long over BR at neck of radius

- incise BR in line of incision

- identify fat covering superficial Radial Nerve

- beneath this branch is arcade of Frohse and PIN

- extend proximally and distally till released

 

Results

 

Jebson et al J Hand Surg Am 1997

- surgical release in 31 patients

- excellent or good results in 67%, fair or poor in 33%

 

Lee et al J Plast Recons Aesthet Surg 2008

- 86% good results in isolated radial tunnel syndrome

- dropped to around 50% if

- other nerve compression / lateral epicondylitis / workers compensation

 

 

 

 

 

 

Wartenberg's Syndrome

Definition

 

Compression of superficial branch radial nerve by ECRB / BR

 

Symptoms

 

Parasthesia first dorsal webspace

 

Associations

 

Up to 50% of patients also Dequervain's

 

Management

 

Non operative

 

Splint

HCLA

 

Operative

 

Surgical release / neurolysis

 

 

 

Ulna Nerve

Anatomy Ulna Nerve

Nerve supply

- C7, C8, T1 

- nerve picks up some branches of C7 from the lateral cord

 

Origin

- direct continuation medial cord

- runs between the brachial artery and the vein in the arm

- behind MCNFA

 

Arm

- pierces the medial intermuscular septum to run in posterior compartment

- runs anterior to the triceps

 

Elbow

- enters the cubital tunnel between the medial epicondyle and the olecranon

- running on MCL 

- covered by osbourne's ligament

- gives articular branches to the elbow

 

Ulna Nerve MRI Cubital Tunnel

 

Forearm

- runs between the two heads of FCU (anterior aspect medial epicondyle and proximal ulna)

- branches to (usually) medial 2 FDP and to FCU

- nerve descends on FDP, under the cover of FCU

 

Wrist

- nerve runs with the ulna artery to the wrist

- it emerges on the lateral aspect of FCU

- nerve is ulna to artery

- dorsal sensory branch which runs under FCU and supplies dorsum of hand in region of 1 and 1/2 fingers

- palmar cutaneous branch which supplies sensation over the hypothenar muscles

 

Guyon's canal 

- superficial to TCL

- under volar carpal / pisohamate ligament

- between hook of hamate and pisiform

- nerve is ulna to the artery

- at the distal edge volar carpal ligament divides into a sensory and motor branch

 

Motor branch 

- runs between abductor and flexor digiti minimi 

- through opponens 

- crosses the palm within the concavity of the deep palmar arch

- gives branches to the lateral 2 lumbricals, all the interossei and ends by supplying adductor pollicis

 

 

 

 

Cubital Tunnel Syndrome

Definition 

 

Symptoms & signs from compression of ulnar nerve near elbow

 

Sites of Compression

 

Proximal

 

Arcade of Struthers 

- thick myofascial band, 1.5-2cm wide

- present in 70%

- 8cm proximal to medial epicondyle

- from medial head of triceps to medial intermuscular septum, superficial to nerve

 

Medial intermuscular septum

- with subluxation, nerve may impinge on it 

 

Medial head of triceps

- hypertrophied (body builders)

 

Medial epicondyle

 

Tardy ulna nerve palsy / cubitus valgus

- compression due to valgus deformity of the bone

- previous supracondylar / lateral condyle fracture

 

Cubital tunnel / Osbourne's ligament

 

Anatomy

- walls are humeral & ulna heads of FCU

- floor is MCL

- roof is Osbourne's fascia (continuation of fibro-aponurotic covering of epicondylar groove)

 

Nerve compression 

- occurs in flexion as Osbourne's fascia tightens

- MCL bulges out and tunnel becomes flattened ellipse

 

FCU

 

Nerve passes intramuscular for ~5cm

- penetrates fascial layer to lie on FDP

- proximal and distal compression possible

 

Other

 

A. Lesions in the groove

- medial epicondyle fracture / arthritic spurs / HO

- lipomas / ganglia / osteochondromas / synovitis / rheumatoid nodule

- infection (TB, leprosy) /bleeding (haemophilia)

 

B. Conditions outside the groove

- external compression

- anomalous anconeus muscle

 

C. Subluxation / Dislocation from the groove

- laxity / traumatic tear of fibro-aponurotic roof

 

History

 

Pain on ulnar side of elbow

Pain & numbness in ulnar fingers

Provoked by elbow flexion

Weakness of fine movements

 

Examination

 

Look

- deformity or carrying angle

- full ROM

- wasting intrinsics dorsum hand

 

Wasting Adductor Pollicis Right Hand

 

Feel

- tenderness tunnel

- Tinel's

- subluxation ulna nerve

- sensation in hand / involvement of dorsal and palmar branches

 

Move

 

A.  Power FCU / FDP LF

 

B.  Hand

- intrinsics

- abductor digiti minimi

- adductor pollicis / 1st dorsal interossei (Froment's)

 

Froment's sign

 

Concealed

- C spine

- axilla

 

DDx

 

TOS

- symptoms worse with overhead position

 

C spine

- neck / shoulder pain

 

T1 nerve root lesion

- thenar muscle power will be reduced

- decreased sensation medial forearm

 

C8 nerve root lesion

- IF / MF FDP & FPL weakened

 

Ulna tunnel syndrome

- sensation normal palmar / dorsal branch

- FCU / FDP LF normal

 

Pancoast tumour

 

Systemic illness

- DM

- alcohol

- hypothyroid

- vitamin deficiency

 

NCS

 

High false negative

 

Test with elbow flexed

- < 50 m/s conduction velocity across elbow

 

EMG

 

Denervation in hypothenar muscles in severe cases

 

Management

 

Non-operative Management

 

Options

 

50% resolve with night elbow extension splint

Avoid leaning on elbows

NSAID

Rest / activity modification

 

Operative Management

 

Indications

 

Intrinsic weakness

Failed non-operative > 3/12

 

Options

 

1.  Open release

2.  Endoscopic release

3.  Open release + Nerve transposition

4.  Open release + Medial Epicondylectomy

 

1.  Open release

 

Indications

- mild disease

- normal anatomy

- no subluxation

 

Technique

 

Incision

- 10cm curved incision centred over cubital tunnel

- 1/2 way between olecranon & medial epicondyle

- extended proximally along medial edge of triceps & distally parallel to border of Ulna

 

Danger

- Posterior branch of MCNFA

 

Superficial dissection

- deepened through deep fascia

- nerve identified in proximal tunnel

 

Release

- proximally ensure no arcade of Struthers

- release Osbourne ligament

- distally release fibrous band of FCU

- ensure ulna nerve stable at end of case

- if unstable, transpose

 

Dangers

- protect distal muscular branches

- 2 branches to FCU 

- branch to FDP

 

Ulna Nerve ReleaseUlna nerve release test stability

 

Results

 

Ziowodzki et al JBJS Am 2007

- meta-analysis of decompression v anterior transposition

- no deformity or previous surgyer

- no evidence of improved outcome with anterior transposition

 

Vogel et al Br J Plastic Surg 2004

- revision surgery in 22 patients

- combination of simple release and subcutaneous transposition initially

- findings were scarring / incomplete release medial intermuscular septum / incomplete FCU release

- all had submuscular transposition and Z lengthening of CFO

- 78% satisfaction rate

 

2.  Endoscopic Release

 

Indication

- normal anatomy / simple release

- no SOL / ganglion requiring removal

 

Technique

 

Small incision over epicondylar groove

- release osbourne's ligament under vision

- lift skin flaps with special retractor proximally and distally

- insert 30scope

- release remainder ulna nerve under endoscopic vision

 

Results

 

Watts et al J Hand Surg 2009

- compared results from open and endoscopic release

- greater patient satisfaction in endoscopic with fewer complications

 

3. Nerve Transposition

 

Indication

- subluxation

- valgus deformity / FFD

- failed decompression / revision surgery

 

Advantage

- allows functional lengthening of nerve 3-4cm

- low recurrence rate

 

Disadvantage

- scar formation with possible new proximal site of compression

 

3 options

 

A.  Submuscular

- muscles elevated from CFO protecting MCL 

- nerve transposed anteriorly

- muscles reattached

 

B.  Intra-muscular

- 5 mm trough made in CFO 

- nerve transposed into groove

- superficial fascia closed over nerve

 

C.  Subcutaneous

- nerve transposed anterior medial epicondyle

- sutcutaneous tissue from skin flap sutured to muscle fascia behind nerve

 

4. Medial Epicondylectomy

 

Indications

- valgus deformity

- malunited fracture

- bony abnormality

 

Disadvantages

- produces scarring

- protection of medial epicondyle lost / pain if lean on elbows

- weakens flexors (contraindicated in athlete)

- MCL injury can occur

 

Technique

- nerve identified, released & protected

- CFO elevated

- medial condyle & supracondylar ridge removed

- guide is medial border of trochlea

- flexor origin attached to periosteum

- MCL should be left attached as it is deep & lateral

 

Complications

 

Hypertrophic scar

Neuroma MCNF

RSD

Non resolution of parasthesia

Ulna Tunnel Syndrome

Definition 

 

Symptoms & signs from compression of ulnar nerve in guyon's canal

 

May be purely sensory, purely motor or combination

 

Anatomy Guyon's Canal

 

4cm long ulnar tunnel

 

Floor - transverse carpal ligament

 

Roof - volar carpal ligament and pisohamate ligament

 

Walls - pisiform (ulna) & hook of hamate (radial)

 

Contents 

 

Ulna nerve and artery

- nerve ulnar to artery

 

Within canal at distal margin ulna nerve divides into 2

- superficial sensory

- deep motor branch

- separated by common tendinous origin of hypothenar muscles

 

3 zones

 

1.  Proximal to bifurcation ulnar nerve - motor and sensory branches

2.  Medial & distal to bifurcation - motor branch

3.  Lateral & distal to bifurcation - sensory branch

 

Aetiology

 

Intrinsic 

 

Soft tissue masses (including ganglia) 46%

Anomalous Muscles 16%

 

Extrinsic

 

Repeated blunt trauma 

 

Can also get

- thrombosis of ulnar artery / hypothenar hammer syndrome

- fracture of hamate (Golfer)

- aneurysm ulnar artery

 

History

 

Pain & paraesthesia in ulnar hand & fingers

 

Weakness hand

- difficulty fine motor skills

 

Examination

 

Look 

- hypothenar wasting / intrinsic wasting / ulna claw hand

 

Feel

- decreased sensation in LF

- decreased sensation hypothenar eminence / dorsal branch suggest higher lesion

 

Motor

- intrinsic weakness / abd digiti minimi / adductor pollicis / 1st dorsal interossei

 

Special

- Tinel's over Guyon

- Allen's test 

 

Cervical spine

 

DDx

 

Cubital Tunnel Syndrome

TOS

Cervical root compression

 

NCS / EMG

 

Confirm Guyon's canal site of compression

 

X-ray

 

Tunnel view

- hamate fracture / pisiform OA

 

MRI

 

Ganglion

 

Management

 

Non-operative Management

 

Restrict exacerbating activities

Splint in neutral

NSAIDs

 

Operative

 

Release

 

Incision

- radial border of FCU 

- 3 cm proximal to wrist crease 

- across crease and along line of ring finger 

 

Superficial dissection

- ulnar nerve isolated proximal to  wrist 

- followed into Guyon's canal 

 

Deep dissection

- divide volar carpal ligament

- divide pisohamate ligament

- resect hook hamate or pisiform if needed 

 

Dangers

- injury palmar branch ulna nerve

 

 

 

 

Peripheral Nerve Injury

Anatomy of the peripheral nerve 

 

Endoneurium 

- loose collagenous matrix

- surrounds the individual nerve fibers within the fascicle

 

Perineurium 

- thin, dense connective tissue sheath that surrounds each fascicle

 

Epineurium 

- a loose meshwork of collagen  and elastin fibers 

- provides a supportive and protective framework for the fascicles

- collagen fibers in the epineurium are thicker than those in the endoneurium / perineurium

 

Definition

 

Neuropraxia

- focal demyelination 2° ischaemia

- full recovery by 3 months

 

Axonotmesis

- axon disrupted

 

Neurotmesis

- nerve division

 

Seddon & Sunderland  Grading

 

1st Degree / Neuropraxia

- localised conduction block leading to segmental demyelination

- axons are not injured

- remyelination and recovery < 3 months, no Tinel's

 

2nd Degree / Axonotemesis

- axonal injury with distal segment Wallerian degeneration

- full recovery

- nerve fibres regenerate 1 mm per day

- but > 3 months, advancing Tinel's

 

3rd Degree / Endoneurium disrupted

- incomplete recovery due to fibrosis

- advancing Tinel's

 

4th Degree / Perineurium divided / Epineurium intact

 

Nerve is in continuity but complete block due to scar

 

Poor prognosis

- perineurium disrupted

- becomes filled with scar

- no recovery, no Tinel's

- no SNAP, denervation potential

- no rennervation at 3/12 (polyphasic AP)

 

Often needs repair 

 

5th Degree / Epineurium divided

- 100% divided / neurotmesis

 

6th Deg (added by Susan McKinnon)

- neuroma in continuity

- mixed recovery

 

Injury Response 

 

Wallerian Degeneration

 

Axon dies distally

- remains intact for 3/24 (until stores depleted)

 

Schwann cell proliferation and macrophage ingrowth

- clear distal stump of axoplasm & myelin

- prepares way for new axon 

 

Axon Regeneration

 

Axon sprouts enter distal endoneural tubes

- 1-2 mm/day

- survive if contact an end organ

- sprouts often enter wrong tube & wrong end organs

- some axons fail to cross repair site & form neuroma

 

Axon Guidance 

 

1. Directional Neurotropic Cues 

- target releases tropic factor

 

2. Survival Neurotropic Cues 

- tube supports correct axon

 

3. Mechanical Alignment 

- worst

 

4. Contact Recognition 

- path selection based on surface

 

Sensory Fibres

 

Survive years of degeneration

- sensory return order

- pinprick / moving touch / constant touch / vibration

 

Muscle Fibres

 

Myofibrils atrophy without nerve

- 50% in 2/12

- fibrotic by 12/12

- need to repair < 9/12

 

Neuromuscular Junction

 

Receptor dispersal over 12 months

- needs to be re-innervated prior to 12 months

 

Receptor becomes more sensitive to ACh

- spontaneous fibrillation start Day 10 

- significant EMG changes > 2/52 

 

Neuronal Response

 

Cell body dies if very proximal axon injury

- 2° ion leakage

- if neurone survives body & nucleolus enlarges

- regenerative proteins produced

- responsible for delay in nerve recovery / regeneration

 

Mechanism Injury

 

1. Open wounds

 

2. Compression

- pressures > 30 mmHg impair venular epineural flow

- retards axonal transport

- alteration in intraneural BV permeability

- leads to nerve function deterioration 

- relative to length of compression & absolute pressure 

 

Tourniquet

- UL 200 mmHg / Max 90 min

- LL 300 mmHg/ Max 120 min

 

3. Traction

 

4.  Thermal 

 

5.  Irradiation Neuritis

 

6.  Injection

 

Recovery Assessment

 

EMG

 

Denervation

- 3 weeks

- fibrillation potentials

- positive sharp waves 

- spontaneous AP

 

Reinnervation

- polyphasic AP  

 

Tinel's Sign

 

Percuss along the nerve

- transient tingling in nerve distribution not at injury site

- indicates axonal sprouts progressing along tube that haven't remyelinised

- response fades proximally secondary to progressive myelinization

 

Sweat Test

 

Sympathetic fibres very resistant to injury

- sweat preservation 

- 20+ magnification lens 

 

Management

 

Outcome Factors 

 

General

- age of patient / most important / < 30 best prognosis

- level of injury (proximal worse than distal)

- health of patient

- time delay to repair

- pure sensory nerves do better than mixed nerves

 

Local

- cut or crush

- single or double level

- surgeon factors

- nil gap, no tension on repair

 

Contraindications to Repair

 

Noncompliant patient

Elderly

Hopeless outcome

Insignificant nerve eg SRN -> surgery to avoid neuroma

Insufficient skills

 

Types of Repair

 

1.  Direct

 

Epineurium repair without tension

 

Primary repair

- best chance of fascicular matching / best fit

- minimal retraction & gap formation

- historically best results

- 8/0 or 9/0 nylon

 

Fascicular Repair

 

Not usually indicated except

- distal 1/3 forearm median nerve

- distal 1/3 forearm ulna nerve

- sciatic nerve in thigh

 

Approach

 

Median nerve

- release PT and FDS radial insertion

- can transpose anterior to pronator and FDS

 

Results

 

Rujis et al Plastic Recon Surg 2005

- meta-analysis

- age > 40 / proximal lesions / delay to repair poor prognostic indicators

 

2.  Nerve Grafting 

 

Indications

- gaps > 2.5 cm

 

Options

- cable graft

- vascularised graft

 

Cable graft

 

Graft options

- Sural / MCNF / LCFN / Saphenous

 

Vascularised graft

 

Technique

- mobilise on BV pedicle

 

Advantage

- faster recovery

 

3.  Neural tubes

 

Description

- absorbable synthetic tubes

- epineurium sutured to each end of tube

- nerve fibrils grow into and along tubue

 

Advantage

- tension free repair

 

Results


Aberg et al J Reconst Plast Aesthet Surg 2009

- RCT of epineural repair v tube in sharp distal median and ulna nerve injures

- no difference between two groups

 

3. Nerve Transfer 

 

4. Neuroma 

 

Resect, diathermy & bury nerve end deeply in good tissue not bone 

 

 

Tendon Transfers

Median & Ulna Nerve

IssuesMedian and ulna nerve injury

 

Extremely difficult

- goals of rehab must be realistic

- limited number of donors

- static procedures more prominent

- fusions, tenodesis and capsulodeses must be used

 

Goals

 

1.  Thumb Opposition

 

EIP to APB and EPL 

- via pulley around Pisiform and FCR

- alternative is Palmaris longus or ADM

 

2.  Thumb Adduction 

 

BR / ECRB + PL graft to P1

- via base of MC III as Adductor

 

3.  Thumb to index tip pinch

 

APL slip with free graft to 1st dorsal interosseous

 

+/- Arthrodesis thumb MP

 

4.  Thumb to LF tip pinch

 

EDM to deep transverse lig

EDC to little must work

 

5.  Power Flexion of fingers 

 

ECRL to all 4 fingers

 

Technique

- using 4 tail graft to lateral sheath or A2 pulley via lumbrical path

 

Alternative

- free gracilis graft

- into FDP

- insert vascularized ulna graft to power

 

6.  Sensation median nerve

 

Superficial radial nerve translocation

Median Nerve

Aetiology

 

High Lesion

- elbow fracture or dislocation

- forearm fracture

- penetrating forearm wound

 

Low Lesion

- laceration at wrist

- distal radius fracture

- carpal dislocation

- entrapment in carpal tunnel

 

Clinical Features

 

1.  Low Lesion

 

A.  Loss Thumb function

- paralysis of APB & Opponens 

- variable FPB

- 1/3 have enough opponens power not to need transfer

 

B.  Parasthesia Radial 3 1/2 fingers and palm

 

2.  High Lesion

 

Above +

 

C.  Loss flexion index and middle finger

- lose FDS IF / MF / RF / LF 

- lose FDP to IF / MF

 

D.  Unable to flex thumb IPJ

- FPL

 

E. FCR + PT 

 

3.  Anterior Interosseous Nerve Palsy

 

Benediction sign

- loss FDP & FPL

- index finger and thumb straight

- middle finger is flexed due to quadriga of MF / RF

 

Weakness of pronation

- pronator quadratus

 

No thenar weakness or sensory loss

 

Management

- thumb: BCR to FPL

- IF / MF: FDP buddy to RF / LF / ECRL to FDP / fuse DIPJ

 

Management

 

Initial

 

Open injury

- Explore & repair

 

Closed injury

- Reduce fracture or dislocation

- Explore if fails to improve after 3/12

- NCS / EMG first

 

Physiotherapy

 

Maintain Joint ROM / Prevent Contractures

 

Goals

 

1.  Flexion IF / MF

- ECRL to FDP IF / MF

 

2.  Flexion RF / MF

- fusion DIPJ or

- buddy to RF / LF FDP

 

3.  Thumb IPJ flexion

- BR to FPL

 

4.  Thumb Opposition

- EI to APB or

- RF FDS to APB

 

4.   Sensation thumb & radial side IF 

- for pinch grip

 

Oppensplasty

 

High median nerve / Extensor indicis to APB

 

Harvest EIP

- incision over index MCPJ

- EIP divided with some extensor hood

- hood repaired

 

2nd incision over dorsum of hand 

- free EIP from EDC

 

Incision over dorsoulnar wrist 

- displace tendon ulnarward

- tendon passed subcutaneously ulnar aspect of wrist to pisiform which acts as a pulley

 

Tunnel across palm to thumb MCPJ

- interwoven into APB & EPL tendon

 

Low Median Nerve / Opponensplasty with RF FDS

 

Reason

- have strong Adductor Pollicis / 1st dorsal interosseous / EPL 

- they will overpower a weak transfer

 

Technique

- loop of FCU at pisiform for pulley for donor

- pass donor through loop 

- tunnel subcutaneously across palm & attach to tendon APB

Principles

Rule of 13 S's 

 

In a Sensible patient, I will transfer a

- Strong, Sacrificeable, Synergistic tendon with Sufficient excursion

- Straight through a Scarless, Stable bed, Subcutaneously

- across a Supple, Sensate joint

- to achieve a Single function by Securing distally

 

Patient

- Sensible

 

Tendon

- Strong (will lose 1 grade of power)

- Sacrifice able

- Synergistic

- Sufficient excursion

 

Surgery

- Straight

- Subcutaneous

- Straight pull

- Secure distally

- Single function

 

Joint

- Supple

- Sensate

- Scarless

 

Definition

 

Tendon transfer

- tendon of a functioning muscle is mobilised, detached or divided

- reinserted into a bony part or into another tendon

- to supplement or substitute for the action of the recipient tendon

 

Tenodesis 

- the detachment of a tendon & its attachment across a joint

 

Tendon Graft 

- when proximal & distal ends of a tendon are transected

- interposed into another tendon pathology

 

Indications 3R's

 

1. Replacement for lost function

- nerve injury 

- neurological disease 

 

2. Replacement of ruptured or avulsed tendons

- RA

- EPL in wrist fracture

 

3. Restoration of balance to a deformed limb

- Cerebral palsty

- stroke

 

 

 

 

Radial Nerve

Issues

 

1. Loss of wrist extension

2. Loss of finger extension

3. Loss of thumb extension

 

Aetiology

 

High lesion (loss of wrist extension)

- humeral fracture (Holstein Lewis)

- compression (Saturday night palsy)

 

Low lesion (PIN - wrist extension intact)

- fracture / dislocation elbow

- trauma / laceration

- iatrogenic - ORIF proximal radius

 

Clinical Features

 

High lesion

- triceps weakness uncommon (lesion usually past triceps innervation)

- wrist drop (ECRL, ECRB)

- inability to extend MCPJ (EDC)

- inability to extend thumb (EPL, EPB)

- sensory defect in anatomical snuffbox

 

Low lesion

- triceps intact

- wrist extension ECRB / ECRL intact

- no sensory deficit

- inability to extend MCPJ (EDC)

- inability to extend thumb (EPL, EPB)

 

Splints

 

1.  Radial Splint / Lively splint

- rubber bands & outrigger

- bands replace EPL / ECRB / EDC

 

2.  Simple static extension splint

- passive ROM to maintain supple joints

 

Investigation

 

NCS at 3/52 

- SNAP intact - neuropraxia

 

EMG at 3/12

- no reinnervation potentials

- poor prognosis

 

Options

 

1.  Explore at 4/12 if no recovery

 

Terzis et al Plast Recon Surg 2011

- surgical repair in 35 radial nerves

- 77% good outcome

 

Lee J Hand Surg Am 2008

- sural nerve grafting of high radial nerve injury

- 80% good or excellent results in regards motor function

 

2.  Tendon transfers

 

Indications

- no recovery at 6 - 9/12

- usually 1 mm / day

- should see ECRL by 6 months

 

Tendon Transfers

 

Goals

 

1.  Wrist Extension / ECRB

 

Pronator Teres

 

2.  Digit Extension / EDC

 

A. FCU

 

Problem

- is the most important wrist flexor

- only ulnar deviator / may result in radial deviation

 

B.  FDS middle finger

 

C.  FCR

- many authors favour 

- gives strong grasp 

 

3.  Thumb Extension / Abduction

 

A.  PL to EPL 

- line of pull via 1st dorsal compartment

- works well as gives some abduction

 

B.  FDS to RF (if no PL)

- can pass through intra-osseous membrane or tunnel subcutaneously

 

High Radial Nerve Transfers

 

Basis is use of PT for wrist extension

 

Jones Transfer

1.  PT to ECRL / ECRB

2.  FCU to EDC

3.  FCR to EPL (+ EPB & APL)

 

Problem is that both wrist flexors are transferred

- loss of FCU may lead to radial deviation

 

Brand Transfer

1.  PT to ECRB

2.  FCR to EDC

3.  PL to rerouted EPL

 

Problem 

- PL absent in 20% 

- alternative FDS RF / MF

- take through interosseous membrane or tunnel subcutaneously

 

Boyes

1.  PT to ECRL / ECRB

2.  FCR to EPB & APL

3.  FDS MF / EDC

4.  FDS RF / EPL & EIP

 

Technique Brand Transfer

 

Set up

- tourniquet

- arm table

 

Incisions

 

1.  PT incision

- over insertion on midportion radius

- dissect between ECRL and ECRB

- take entire periosteal insertion off radius

- need to keep long

 

2.  FCR / PL incision

- distal volar incision

- take both tendons as distal as possible

 

FDS RF

- make incision in palm over A1 pulley of RF

- if need FDS to RF must take proximal to bifurcation

 

3.  Dorsal incision

- proximal to extensor retinaculum, expose EDC and EPL

 

Transfers / Tensioning

 

1.  PL to EPL

- tunnel PL / FDS subcutaneously under SRN to EPL

- place thumb abducted and extended

- pulve taft weave

- through tendon 4 times at 90 degrees to each other 

- 4.0 ticron stitches at each pass

- check tension

 

2.  FCR to EDC

- pass FCR through all 4 tendons of EDC

- may need to take through EDMB

- check tension

- fingers should be in cascade in wrist flexion

- full extension with wrist extension

 

3.  PT to ECRB

- PT passed through ECRB with wrist in full extension

- again check tension

 

Post op

 

0 - 4 weeks splint

- wrist and MCPJ extension

- active finger extension (DIPJ, PIPJ)

 

4 - 6 weeks

- active MCPJ extension

 

Wrist flexor to finger extensor

- teach patient to flex wrist & extend fingers

- after a while they can extend fingers without flexing fingers

 

Pin Palsy Transfers

 

Wrist extension not required

 

Transfers

- FCR to EDC

- PL to EPL

 

 

 

Ulna Nerve

Aetiology

 

Low Lesion (Below Elbow)

 

Injury usually at wrist

- laceration at wrist

- fenetrating forearm wound

 

Ulna nerve laceration wrist

 

High lesion / Above elbow

 

Injury usually at elbow

- elbow fracture / dislocation

- compression (GA) 

- tardy ulna palsy

 

Low Lesion

 

1.  Claw hand deformity

 

Characteristics

- hyperextension all MCPJ 

- flexion of IPJ of Ring & Little fingers

 

A.  Absent lumbricals - loss of MCPJ flexion / IPJ extension to RF & LF

 

2.  Unopposed MCPJ extension - EDC 

 

3.  IPJ flexed by long flexors - less marked in high lesion because ulnar FDP paralysed

 

2.  Loss of interossei 

 

Weak finger abduction / adduction

Positive Froment's sign

Hypothenar & Interossei wasting

 

Froment's

 

3.  Numbness of ulnar  1 & 1/2 fingers

 

May have numbness of ulnar dorsum of hand

- depends on level of lesion

- if forearm, take out dorsal branch ulna nerve

 

High Lesion


Above +

 

A.  RF / LF FDP loss

- ulna paradox with less clawing 

 

B.  FCU weak

- weak wrist flexion

 

Goals

 

1.  Restore pinch / thumb stability

- thumb adduction (interposition to BR/ECRB)

- index abduction (EPB to 1st Dorsal Interossei)

 

2.  Correct MCPJ clawing

 

Management Low Ulna Palsy

 

1.  Thumb adduction

 

No donor long enough

- FDP LF tendon to BR / ECRB

 

Technique

- need interposition graft  i.e. FDP to LF)

- graft fixed to base P1 / normal insertion

- tendon passed along a line form base of MC III /  line of pull of Adductor

- bring out through dorsum between III and IV MC's

- attach to donor tendon BR or ECRB

 

2.  Index Finger abduction

 

EPB to 1st dorsal interossei

 

3.  Clawing of MCPJ

 

Goal

 

Prevent hyperextension of MCPJ's

- Want to create FFD

 

Options

 

Static

- Zancolli Capsulodesis / volar plate advancement

 

Dynamic

- reconstruction lumbricals

- split MF FDS / ECLR into 4

 

Zancolli Capsulodesis 

 

Transverse palmar incision

- each A1 pulley opened

- flexor tendons retracted

 

Volar plate raised as distally based flap & advanced proximally

 

Finger flexed to 20°

- volar plate sutured to new position

- mild FFD MCPJ created

 

Management High Ulna Palsy

 

1. FDP to ring and little

 

Buddy to middle FDP

 

Problem

- FDP flexes IPJ's before MCPJ's

- this unopposed flexion of IPJ can push object out of palm

 

2. FCU

 

Split FCR to FCU

 

 

 

 

 

Shoulder

ACJ

ACJ Arthritis

Aetiology

 

Post-traumatic (type III clavicle fractures)

Idiopathic

 

4 patterns 

 

1. OA with osteophytes 

-  contribute to impingement

 

 Acromioclavicular Arthritis

 

2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)

 

ACJ OsteolysisACj Osteolysis

 

3. RA

 

4. Hyperparathyroidism

 

Symptoms

 

Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm

 

Signs

 

ACJ OA Clinical Photo

 

Tenderness to direct palpation is most reliable sign

- may feel osteophytes

- must compare to ensure other side is not tender (but may have bilateral ACJ OA)

 

Cross body adduction of arm 

- tends to overlap with impingement

 

Diagnosis

 

LA + Cortisone

- inject into joint

- diagnostic / therapeutic

 

DDx

 

Intrinsic

- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis

 

Extrinsic

- Cervical root C4/5

- shoulder tip pain from abdominal pathology

 

Xray

 

Zanca view

- AP 10° cephalic tilt with 50% penetration 

 

ACJ OA Inferior Clavicle Osteophyte

 

Bone Scan

 

Not usually necessary

 

ACJ OA Hot Bone Scan

 

Management

 

Non-operative

 

Most patients respond well

NSAIDs

Activity modification

Steroid injection

 

Operative

 

Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment

 

Aim

 

Resect sufficient distal clavicle to prevent abutment

 

Options

 

1.  Open excision distal clavicle

2.  Arthroscopic resection

 

Open Excision of distal clavicle

 

Post Open ACJ Excision

 

Technique

- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact

 

90% success rate

 

Arthroscopic ACJ Resection

 

Advantage

- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation

 

Results

 

Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

- identified subtle intra-articular changes not seen on MRI  which were treated

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection

 

Technique

 

1.  Identify distal clavivle

- remove bursa and perform SAD

- use electrocautery from lateral portal to identify the distal clavicle (push down on clavicle repetitively)

- clean and identify clavicle anterior and posterior

 

ACJ OA 1ACJ OA 2

 

2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

- must remove full thickness of distal clavicle superiorly / be able to visualise superior AC ligament

- must not leave posterior edge

 

ACJ OA 3 Anterior CannulaACJ OA Debridement 1ACJ OA Debridement 2

 

Post Arthroscopic ACJ resectionSuperior AC Ligament post arthroscopic resection

 

 

 

ACJ Dislocation

Type 3 ACJ Dislocation

Anatomy

 

Synovial joint with hyaline cartilage

 

Has fibrocartilage intra-articular disc

- complete or incomplete

- usually degeneration by 4th decade

 

Clavicle may lie superior to acromion in normal population

 

Acromioclavicular Ligaments

 

ACJ capsule

- strongest superiorly

- horizontal / AP stability

 

Coracoclavicular Ligaments / CCL

 

Primary restraint to superior translation

- primary suspensory ligament of upper limb

 

Trapezoid Ligament (anterolateral)

- anterolateral on coracoid

- inserts trapezoid ridge also anterolateral to conoid

- almost horizontal in sagittal plane

- primary restraint to axial compression

 

Conoid Ligament (posteromedial)

- arises postero-medial to trapezoid

- inverted cone

- inserts conoid tubercle

- apex of posterior clavicular curve

- junction lateral & medial 2/3

- lies vertically

- primary restraint to superior and anterior translation

 

Delto-trapezial fascia

- dynamic stabiliser

 

Motion at ACJ

 

Only small 5-8o

- 40o at SC joint

- motion is at scapulo-thoracic joint rather than ACJ

 

Aetiology

 

Usually direct force onto adducted shoulder joint

- clavicle remains in normal position

- arm falls down

 

Examination

 

Usually clinically obvious

 

Grade 3 ACJGrade 3 ACJ

 

Allman grades I-III 1967 / Rockwood modified 1989 Classification

 

I     ACJ sprain

 

II    ACJ Disrupted & CCL intact / sprained

 

ACJ Dislocation Grade 2

 

III  Rupture ACJ & CCL 

- displaced > 100% of clavicular width

 

Grade 3 ACJ Dislocation

 

IV   Into trapezius

- can be easily missed

- need axillary lateral

 

Type IV ACJ APType IV ACJ Axillary LateralType IV ACJ

 

V     High dislocation > 1 x clavicle width

- disrupted trapezius & deltoid

- end of clavicle subcutaneous

 

ACJ Dislocation Type 5

 

VI    Subcoracoid dislocation

 

X-rays

 

Zanca view

- specific for ACJ

- 10ocephalad, 50% voltage

 

Stress views

- occasionally used

- hold weights in each arm

- bilateral xray

 

Normal 

- 50% overriding clavicle

- 2% under riding

- 29% incongruent

- joint width 0.5-7 mm

 

Management

 

Type I

 

Symptoms 7-10 days

- RICE

- Avoid heavy stress & contact sport till FROM & no pain to palpation

- 2/52

 

Type II

 

Sling 2/52

- avoid heavy lifting, contact sports 8-10/52 to allow ligament healing

- OT if Persistent pain

        

Chronic Symptomatic I & II

- trapped capsular ligament / loose articular cartilage / detached meniscus

- excision outer end clavicle if continued symptoma

 

Acute Type III

 

RCT Operative vs Non-Operative

 

Tamaoki et al Cochrane Database 2010

- meta-analysis of 3 RCT

- operative v non operative

- multiple fixation techniques

- no obvious advantage in operative group

- RCT insufficient to decide merit of operative management

 

Surgical Indications

 

Rockwood

- heavy labourer

- < 25 years undecided on career

- not in athlete (will just destroy repair when next falls)

 

Options

 

1.  Hook plate

- reduction of ACJ

- hook under posterior acromion

- allows CC ligaments to heal

- must be removed

- but can mobilise the shoulder at 4-6 weeks with implant in situ

 

Clavicle Hook Plate

 

Gstettner et al J Should Elbow Surg 2008 

- acute injuries

- hook plate or non operatively, patient choice

- 57 v 30

- hook plate removed after 3 months

- 1 hook plate cut up through acromion (still good result)

- 3 superficial infections

- slightly improved constant scores in surgical group

- similar ROM

- improved pain and power scores

 

Risks

- acromial cut out

- clavicle fracture

 

Clavicle Hook Plate Fracture

 

2.  Reconstruction

 

Chronic Symptomatic Grade III

 

Excision distal clavicle

 

Poor results

- convert long high riding clavicle to short high riding clavicle

 

Reconstruction Options

- Phemister technique

- Weaver Dunn

- CCL augmentation (anchors / tightrope)

- CCL Reconstruction

- combinations

 

1.  Phemister technique

 

Technique

- open reduction of ACJ

- 2 x K wires across ACJ

- suture repair AC and CC ligaments

 

Calvo J Should Elbow Surg 2006

- Phemister v Non operative

- similar rates of deformity (i.e. non anatomic reduction) 

- less radiographic OA in non surgically treated cases

- may be that K wires further damage joint

- similar functional results in each

- recommend non operative treatment

 

2.  Weaver Dunn Reconstruction

 

Concept

- reconstruction of CC ligament with coraco-acromial ligament (CAL)

- CA ligament left attached to coracoid

- excise 1.5 (2.5cm original recommendation) lateral clavicle

- CAL taken off anterior acromion with bone fragment

- transferred from acromion to clavicle end / intra-osseous suture repair

 

Supplement with

- hook plate

- Bosworth Screw

- anchor / sutures

- Lars Ligament / Hamstring / allograft

 

3.  CCL Augmentation

 

Technique

- 5 mm anchor with sutures about clavicle

- tightrope constructs

- Bosworth screw

 

Weaver Dunn with Twinfix AnchorACJ Reconstruction TightropeACJ Reconstruction Tightrope

 

4.  CCL Reconstruction

 

Technique

- pass allograft / autograft / LARS around coracoid

- pass around clavicle and suture or

- can pass through drill holes and secure with screws

- second technique risks clavicle fracture

 

Results

 

Tauber et al J Should Elbow Surg 2007

- 12 revision cases of failed Weaver Dunn

- autogenous ST in figure 8 configuration

- through drill holes in clavicle, around coracoid, then over clavicle

- augmented with Bosworth / TBW removed at 3/12

- 4 weeks immobilised, then ROM to 90o for another 8 weeks

- good results, one clavicle fracture from wire

 

Complications 

- intra-operative fracture coracoid

- failure repair (10 - 20%)

- recurrent deformity common in surgical groups

- clavicle fracture (due to sutures or metal work)

- ACJ OA

- continued pain

- posterior dislocation (due to non intact AC ligament)

- NV damage

 

Type IV, V, VI

 

Most recommend surgery

- hook plate / reconstruction acutely

- reconstruction late

 

Technique Weaver Dunn + Augmentation / Reconstruction

 

Approach

- 45o beach chair

- sabre incision over ACJ

- split fascia transversely along the clavicle and onto acromion

- must skeletalise distal end of clavicle to beyond former insertion of conoid and trapezoid

- expose anterior aspect of acromion

- resect 1 cm of distal clavicle with microsagittal saw

- find the CA ligament which will run from anterior acromion down to coracoid

- often a great deal of scar tissue in this area from injury

- expose the coracoid laterally and carefully medially

- take off anterior 5mm of acromion and carefully peel CAL off the underlying SSC

- will need to release some of CAL from coracoid to get sufficient length

 

Reduction / Reconstruction

- reduce clavicle down with preferred technique

- 5mm anchor / tightrope / allograft / autograft / Lars ligament through drill holes

- cross graft at clavicle so gives front to back stability as well as superior / inferior

- place drill holes through distal clavicle

- use 2 fibre wire to weave through CAL under bony fragment

- secure with intra-osseous sutures

 

Post op

- sling for 6/52

- no contact sports for 6/12

 

Post Weaver Dunn with Lars Ligament

Os Acromiale

Definition 

 

Failure of fusion of adjacent ossification centers

 

Epidemiology

 

Incidence 3%

 

Bilateral in 60%

 

Anatomy

 

4 ossification centers present in acromion

- pre-acromion

- mesoacromion

- metaacromion

- basiacromion

 

The basiacromion fuse to spine of scapula by 12

 

Pre / Meso / Meta appear by 18

- Unite by age 22 - 25

- If un-united = Os Acromiale 

 

Types

 

1.  Meso-Acromion

-  most common

- level with posterior aspect clavicle

 

 Os Acominale XrayOs Acromionale MRI AxialOs Acromionale MRI Sagittal

 

2.  Pre-acromial

- less common

- level with anterior border acromion

 

 Os Acrominale MRI T2

 

3.  Meta-Acomial

- rare

 

X-ray

 

Best seen on axillary lateral

 

Factors favoring diagnosis of os acromiale over fracture 

- bilateral occurrence (Xray other side)

- rounded borders with uniform space

 

MRI

 

Useful investigation

- may show oedema if problematic

 

Os Acromionale MRI 1Os Acromionale MRI 2

 

Bone scan

 

Can be very important

- unlikely to be symptomatic if cold

- may be symptomatic / need addressing if hot

 

Symptomatic Os Acromionale

 

1.  Non union

- painful

- MRI / bone scan shows inflammation

 

2.  Dynamic impingement

- fragment moves with deltoid contraction

- decreases size of SS outlet

- impingement symptoms

 

Os AcromionaleOs Acromionale 3

 

Surgery

 

Indications

- failure of non operative treatment

 

Options

 

1.  Excision

- small fragment / pre-acromion

- risk defunctioning deltoid

- can perform arthroscopically and leave deltoid attachment intact

- open excision with careful reattachment

 

Pagnani JSES 2006

- arthroscopic excision in 11 shoulders of athletes

- all returned to sport at 14 weeks

- no loss of strength detected

 

Os Acromiale Arthroscopic

 

2.  ORIF

- large fragment / mesoacromion

- take down non union

- bone graft / 2 x AP 3.5 mm screws / TBW

- especial care with deltoid reattachment

 

Os Acromionale ORIF 1 Os Acromionale ORIF 2Os Acromionale ORIF 3

 

Risk of nonunion

 

Os Acromionale Nonunion 1Os Acromionale Nonunion 2Os Acromionale Nonunion 3Os Acromionale Nonunion 4

 

Peckettet al JSES 2004

- ORIF in 26 patients

- Union 25/26, 2 fractures

- 30% required removal metalwork

 

3.  Arthroscopic SAD

AVN Shoulder

Shoulder AVN

 

Epidemiology

 

Much less common than hip OA

- usually presents late

 

Aetiology

 

Similar causes as hip (AS IT GRIPS 3C)

 

Alcohol / Steroid / Trauma / Idiopathic

 

Gauchers

 

RA / RTx

 

Sickle Cell 

- commonest cause worldwide

- bilateral

 

Caisons / Chemotherapy

 

Blood Supply

 

Gerber JBJSA 1990

 

1.  Anterior Circumflex Humeral Artery

- primary blood supply

- becomes arcuate artery

- runs lateral aspect bicipital groove

 

2.  Posterior Circumflex Humeral Artery

- collateral circulation

- supplies head when GT / LT fracture

 

3.  Via Rotator Cuff

 

Fracture

 

Wide range of AVN after 4 part fractures

- about 1/3

 

Recent studies to explain this

 

1.   Suggest 2nd anastomotic system 

- via posteromedial branches of PCHA along inferomedial capsule

- blood supply may be further compromised by large exposure in ORIF

 

2.  Creeping substitution

- occurs more extensively in humeral head

 

3.  Rich vascular tissue surrounding humeral head

 

Natural History

 

Variable

- Difficult to predict

- Somewhat related to aetiology

- Sickle cell disease tend not to progress to arthroplasty

- Steroid induced far more likely

 

Less severe than femoral

- non weight bearing

- less conforming joint

- scapulothoracic motion

 

Pathology 

 

Superior head collapse at 90° mark 

- area of peak contact stress in abduction

- ROM Maintained until late

- Glenoid rarely affected

- Soft tissue and SSC rarely contracted

 

Classification / Cruess modification of Ficat-Arlet 

 

Stage 1

- prexray change

- only seen with MRI

 

Stage 2

- sclerotic changes in superior central head

- sphericity maintained

 

Humeral AVN Stage 2Humeral AVN Stage 2 MRI

 

Stage 3 

- "Crescent" Sign

- mild flattening articular surface

 

Shoulder AVN Stage 3

 

Stage 4

- significant humeral collapse with loss integrity joint surface

- loose bodies

 

Shoulder AVN Stage 4Shoulder AVN Stage 4

 

Stage 5

- degeneration extends to involve glenoid

 

AVN Shoulder Xray

 

Symptoms

 

Pain is major problem

- pain before significant loss ROM

- difficulty sleeping

 

MRI

 

Shoulder AVN MRIShoulder AVN MRI Sagittal

 

Management

 

Remove insult

- corticosteroids, alcohol

 

Non Operative

 

Maintain current shoulder ROM / Halt Progression

 

A.  Prevent disuse related stiffness

- passive physio

 

B.  Limit overhead activities

- Joint Reaction Force greatest > 90o

 

C.  Bisphosphonates

 

Operative

 

Core Decompression

 

Decrease intraosseous pressure & increase blood flow

- moderate success mainly in stage 1 or 2

 

Hemiarthroplasty 

 

Usually works well

- glenoid not usually affected

- Soft tissue and subscapularis rarely contracted 

 

Smith et al J Should Elbow Surg 2008

- steroid induced AVN

- survival 92% 10 year

- 2 patients needed revision for painful glenoid arthrosis

- good option

 

TSR

 

Indicated in stage V only

- beware in young patient < 65

 

 

 

Arthrodesis Shoulder

Indications

 

Indications have narrowed

- due to success of shoulder arthroplasty

 

1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Stabilization after resection for neoplastic lesions

 

Contra-Indications

 

Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers (no movement possible)

Charcot arthropathy (low chance union)

 

Advantages

 

Permanent solution

 

Disadvantages

 

Loss of movement at shoulder

Difficulty with activities at head level or behind the back 

Perineal care

Feeding

Loss of movement at other joints 2° prolonged immobilisation

 

Results

 

80-95% patient satisfaction

 

Union rates ~ 95%

 

Aims

 

Rowe 1974 Requisites after Shoulder Arthrodesis

 

1.  Hand should reach face / head / mid-line of the body anteriorly & posteriorly

- thumb to chin

- reach axilla, mouth and belt buckle

- combination of forward flexion and elbow flexion

 

2.  Shoulder be comfortable at rest / scapula should not be prominent

- arm should hang by side with scapula flat against thorax

- no winging

 

Position

 

Rockwood et al JBJS Am April 2001

- Abduction 10-15°

- Flexion 10-15°

- Internal Rotation 45°

 

Issues

1.  Technically difficult to obtain correct position intra-operatively

2.  IR most important to later function

3.  Position in reference to trunk not scapula

4.  Avoid excessive abduction & flexion

- forces the scapula to rotate & wing at rest

- leads to fatigue & discomfort

 

Principles

 

1. Need painless, supple joints above & below

2. Rigidly stabilise congruent vascular cancellous surfaces under compression

3. Bone graft & splint as needed 

 

Options

 

Intra-articular / glenohumeral

 

Extra-articular /  acromio-humeral

 

Combined

 

Principles

 

Approach

 

A.  Posterior

- detach deltoid from spine

- between IS and TM

 

B.  Anterior

- detach deltoid from clavicle

 

Technique

- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- arthrodesis between humeral head and glenoid / acromion

- temporarily fix with steinman pins GHJ and acromion-humerus

- check position / ROM / no winging

- if satisfactory, insert GHJ and acromial-humeral compression screws

- humerus - acromial plate if anterior approach

- humerus - scapular spine plate if posterior approach

 

Complications

 

Early skin breakdown

Loss elbow flexion

Non-union

Mal-union

Painful metalwork

Breakage of metalwork

Suprascapular nerve entrapment

AC joint OA

 

Results

 

Cofield & Briggs JBJS 1979

- 71 fused shoulders

- average 9 year follow up

- 96% union rate

- 75% adequate pain relief

- 70% good functional result

 

 

 

 

Arthroplasty

Hemiarthroplasty Osteoarthritis

Shoulder Anatomical HemiarthroplastyHemiarthroplasty OAShoulder Resurfacing

 

Advantage

 

Fewer complications than TSR

Simpler procedure

Indicated in younger patient

 

Disadvantages

 

Glenoid wear after hemiarthroplasty

- potential for medial migration & progressive glenoid wear

- revision to TSR almost always alleviates symptoms

 

Hemiarthroplasty V TSR for OA

 

Sandow et al J Should Elbow Surg 1999

- study randomized after inspection of glenoid

- less pain with TSR

- high revision rate in Hemiarthroplasty for glenoid wear over time

- had to cease study as TSR results significantly superior

 

Lo et al JBJS Am 2005

- metanalysis

- TSR superior pain relief / active ROM / patient satisfaction

 

Similar in AVN and fracture

 

Less clear for RA

- risk of glenoid component loosening

 

Hemiarthroplasty + Biological Resurfacing

 

Elhassen et al JBJS Am 2009

- 13 patients average age 34

- glenoid resurfacing with achilles allograft

- 10/13 required revision at average 14 months for pain

- all had glenoid wear with no evidence of allograft

 

Indications Hemiarthoplasty

 

1.  Normal glenoid

- AVN / trauma

- replace glenoid later if needed

- simple procedure for elderly

 

2.  Young patient

 

3.  Glenoid insufficient bone stock

 

Clinical Case

 

Patient with OA treated with Hemiarthroplasty

 

Shoulder Hemiarthroplasty for Osteoarthritis AP

 

The patient developed pain 2 years later

Infection was excluded with blood tests

CT and bone scan indicative of glenoid wear

US demonstrated intact rotator cuff

 

CT Shoulder Hemiarthroplasty for OsteoarthritisBone Scan Shoulder Hemiarthroplasty for Osteoarthritis

 

Revision to TSR

- cemented 3 peg glenoid inserted

- modular body removed to access glenoid

- shorter body used to decrease humeral head height

- intra-operative GT Fracture treated with trauma body and sutures

 

Hemiarthroplasty revised to TSR

 

Reverse TSR

Complications

Intraoperative glenoid fracture

 

Avoid by

- careful reaming and drilling osteoporotic bone

 

Management

1.  Rotate metaglene

- use locking screws to stabilise glenoid

2.  PA screws

- cannulated 4.0 mm screws

- inserted percutaneously from posterior

 

Haematomas

 

Great deal of dead space is created

- always use a drain

 

Nerve injuries

 

AXN / MCN

 

Thought to be more prevalent due to increase stretch of plexus compared with TSR

 

TSR Brachial PlexusReverse TSR Plexus Stretch

 

Infection

 

Spacer for Infected Reverse TSR

 

Sabesan et al Clin Orthop Research 2010

- 17 patients treated with 2 stage revision

- 1 recurrence of infection

- 5 dislocations

 

Inferior scapula notching

 

Reverse TSR Notching

 

Cause

- metaglene not placed inferiorly enough

- humeral component impinges on scapular neck in adduction

 

Prevention

 

Inferior tilt / inferior translation / overhand

- place metaglene very inferior

- use eccentric glenoidspheres / overhang inferiorly

- lateralised glenosphere

 

Problem

- may be cause for development of late pain

 

Simovitch et al JBJS Am 2007

- 77 reverse Delta III shoulders

- 44% inferior glenoid notching

- anterior and posterior notching also occurred

- related to height of implantation of glenosphere +++

- less so to the prosthesis-scapular neck angle

- inferior scapula notching related to poorer clinical outcome

 

Loosening

 

Failed Glenoid Reverse TSRReverse TSR Loose Metaglene

 

Dislocation  

 

Dislocated Reverse TSR AP

 

Dislocated Reverse TSRDislocated Reverse TSR Lateral

 

Acromial Stress Fracture

 

Probably due to overtightening

 

Reverse TSR OvertighteningReverse TSR Overtightening 2

 

Xray Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSR 2

 

Reverse TSR Acromial Fracture ORIF

 

Glenosphere loosening from Metaglene

 

Reverse TSR Loose Glenosphere from Metaglene

 

 

Technique

1.  Templating

 

Xray

 

Rotator Cuff Arthropathy

 

AP in plane of scapula

- template glenoid 

- most inferior screw is in thick bone of scapular axillary border

 

AP humerus

- size and fit of diaphyseal and metaphyseal humeral components

 

CT

 

Axial

- assess glenoid bone stock / version

- normally no posterior wear in cuff arthropathy

 

Glenoid Pre Rev TSR Axial CT

 

Coronal

- often superior wear

 

Glenoid Pre Rev TSR Coronal CTGlenoid Pre Rev TSR Coronal CT 2

 

2.  Deltopectoral approach

 

Incision

- long

- need to be able to access clavicle

- make need to perform clavicular osteotomy

 

Approach

- take SSC and capsule off LT and humerus

- often done with osteotomy as per TSR

- identify and protect axillary nerve

- take part of CAL

- remove capsule from inferior humeral neck + any osteophytes

 

3.  Humeral resection using guide

 

Make entry point in humeral head

- hand ream to determine size of stem

- insert stem with cutting block attached

- 0o or 20o (c.f. TSR)

- 155o cut

- plane of cut laterally just below anatomical neck

- usually takes a couple of millimetres of GT

 

4.  Glenoid

 

Remove capsule and labrum

- protect axillary nerve at all times

- mobilise SSC anteriorly

- need to be able to palpate anterior glenoid

- identify axillary border of scapula

- release triceps and capsule inferiorly

- must be able to feel inferior glenoid and spine

 

Good exposure of glenoid is key to reverse TSR

- sandbag behind spine / allows scapula to fall posterior

- tilt bed up on side of operation

- posterior and inferior glenoid retractors

 

Centering Guide wire passed 

- centre of inferior circle of glenoid

- should exit scapula anteriorly about 3cm medial to glenoid

- ensure not too anterior as anterior screws can have little purchase

- ensure inferior screw will be in inferior good bone

- metaglene needs to be positioned low to prevent inferior impingement and dislocation

- wire needs to angle slightly inferior rather than slightly superior

 

Ream

- symmetrically ream

- remove only cartilage, just to subchondral bone

 

Drill central peg hole

 

Insert metaglene

- press fit central peg

- usually only one size

- rotate so superior screw will be in line with base of coracoid

 

Inferior screw

- drill long screw (minimum 35 mm)

- should be in good bone

- is most important screw

- will exit cortex somewhere

- insert locking screw

 

 Reverse TSR APReverse TSR Axillary View

 

Superior locking screw

- feel anterior and posterior edges of coracoid

- aim between

- again will exit cortex

- 25 - 30 mm screw

 

Reverse TSR Coracoid ScrewReverse TSR Axillary

 

Anterior and posterior non locking screws/ not in every design

- are predetermined to be divergent

- get best bite possible

- can use locking or non locking

 

Add glenosphere

- can wait until have done humeral component and trial

- do have option for eccentric glenosphere

- this overhangs inferiorly, preventing notching / impingement / possible dislocation

- otherwise, if happy with position, choose size and screw in place

 

5.  Ream and trial humeral component

 

Set rotation

- is an eccentric option

- ream over trial

- insert stem and metaphyseal component

- add liner (+3, +6, +9)

 

Trial stability

- in full ER will open slightly

- adduct and ensure not dislocating / put hand in armpit

- shuck test - entire shoulder should move first

 

7.  L'Episcopo

 

Consider Latissmus Dorsi transfer

- if no functioning external rotators

- cannot raise hand to mouth

- severe fatty infiltration / tears in IS / Tm

 

Detach LD anteriorly

- pass front to back

- suture via drill holes to the posterior aspect of the humerus

 

LEpiscopo 1LEpiscopo 2

 

8.  Closure SSC / LT

 

Technique

- 5 ticron

- through drill holes in humerus

- pass around stem

 

9.  Rehab

 

Protocol

- 6/52 passive forward flexion

- 6/52 active assist

- at 3-12 begin muscle strengthening

 

 

Theory

Rotator Cuff Arthropathy for Reverse TSR

 

Indications

 

1.  RC arthropathy / > 70 / low functional demand

 

2.  Revision TSR

 

3.  Failed Hemiarthoplasty in proximal humerus fracture

 

Design

 

Reverse TSR Xray

 

In rotator cuff dysfunction

- humeral head superior causing early failure of conventional TSR

 

Professor Paul Grammont

- convex articular surface to glenoid

- concave surface humerus

- shifts centre of rotation medially and distally to glenoid

- improves lever arm of deltoid

 

Limitations of conventional TSR

 

1.  Inability to manage GH translation

 

Fully conforming surfaces

- humeral and glenoid components same radius curvature

- rim loading must occur with any translation

- rocking horse mechanism

 

Non conforming surfaces

- glenoid radius curvature > humeral head

- diminishes contact area

- increases local contact pressure

- risk poly failure

 

2.  Limitation of fixation of poly to glenoid

- subject to shear forces             

 

3.  Limitations of stability

 

Anterior instability

- defects SSC or anterior capsule / glenoid

 

Posterior instability

- posterior glenoid deficiency / dysplasia

- deficient posterior capsule or labrum

 

Superior instability

- deficient SS or CA ligament / acromion

- laxity of deltoid means it cannot function

- pseudoparalysis from antero-superior escape

 

4.  Deltoid dysfunction

- unable to raise / lower / medialise centre of rotation to compensate for deltoid dysfunction

- without risking loosening and failure of the glenoid component

 

Features of Reverse TSR  

 

1.  GH translation

- does not permit GH translation

- due to conforming concavity of humeral component

- full surface contact maintained during range

- nil rim loading

 

2.  Glenoid fixation

- metaglene fixed by locking and non locking screws along with a central press fit HA coated peg

- metal glenosphere fixed by press taper

- no poly to metal fixation issue

- medialisation of centre of rotation decreases the lever arm of forces

- reduces the moments that challenge fixation

 

Reverse TSR AP BiometReverse TSR Lateral

 

3.  Intrinsic stability

- nature of design has increased intrinsic stability

- humeral socket  forms an angle of 155o with humeral shaft

- deltoid force acts to stabilise the joint

- less dependence on soft tissue and CA arch

 

4.  Deltoid dysfunction

- able to lower or lateralise COR

- inherent stability allows prosthesis to work even if only part of deltoid functions

  

Results

 

ROM

 

Cuff et al JBJS Am 2008

- 96 patients with minimum 2 years follow up

- abduction increased from 61 to 110o

- flexion 60 to 120o

- ER from 13 to 30o

 

Complications

 

Wall et al JBJS Am 2007

- 191 shoulders followed for a minimum two years

- worst results in post traumatic arthritis and revision TSR

- 15 cases of dislocation

- 8 cases of infection

 

Survival

 

Guery et al JBJS Am 2006

- calculated 10 year survival rate of 90%

- noted than Constant shoulder scores deteriorated over time

- 60% 10 year survival with Constant score < 30 as an end point

 

Revision Shoulder Arthroplasty

Issues

 

Rule out infection

Assess rotator cuff / bone stock preoperatively

Approach

- difficult / scarring +++

- very difficult to restore any loss of ROM

Removal of prosthesis

Glenoid

- may not be able to revise

Humeral component

- long stem

 

Investigations

 

Rule out infection

- CRP / ESR

- ultrasound or xray guided aspiration

- arthroscopy for fluid and tissue sampling

 

Ultrasound

- good for cuff integrity

- MRI often not useful due to large amount of metal artefact

 

CT scan

- glenoid often deficient posteriorly 

- if ignore will either be unstable posteriorly

- or will expose glenoid to excessive forces, predisposing to failure

 

Implant Removal

 

Glenoid

- often very loose

- easy to remove

 

Revision TSR Loose GlenoidRevision TSR Loose Glenoid

 

Humeral component

- most uncemented stems only proximally coated

- flexible osteotomes

 

Revision TSR

 

Glenoid bone stock restoration

 

1.  Cortical ring allograft

- napkin ring type

- take from calcar of a femoral neck

- cut so is thicker posteriorly to reconstitute the glenoid

- place onto freshened glenoid surface

- use uncemented glenoid

- drill central plug, then superior and inferior screws

 

Problems

- bone can crack, making it unstable

- need long screws with good bite, locking screws preferable

- useful to have available custom made implant with longer central peg

- enables obtain fixation with native glenoid

 

2.  Bulk posterior allograft

 

 Revision Reverse TSR Glenoid Bulk Posterior Allograft

 

Technique

- use femoral head

- reconstitute posterior aspect of glenoid

- fix with 2 x cannulated 4mm screws via stab incisions posteriorly

- need to be able to fix glenoid component with screws still

 

Revision Humeral Component

 

Technique

- often need long stem

- often use cement in revision circumstance

 

Revision TSR Long Stem Cemented Humeral Component

 

Rheumatoid Shoulder

IssuesRheumatoid Shoulder

 

Rotator cuff

- often deficient

 

Bone stock

- often deficient

 

Glenoid

- often posterior version 

 

Management

 

Options

 

1.  TSR

 

Indications

- cuff intact

- sufficient bone stock

 

2. Hemiarthroplasty

 

Indications hemiarthroplasty

- young patient

- rotator cuff not intact, too young for reverse

- insufficient bone stock glenoid

 

Technique if rotator cuff deficient

- CTA head

- over size humeral head / increase valgus

 

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR

 

3.  Reverse TSR

 

Indications

- ruptured cuff (30%)

 

Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects

 

 

 

 

TSR Technique

TSR APTSR Lateral

 

Goal

- head that translates 50% in all directions

- allows 30o ER with arm at side

- stable posteriorly

 

Pre-Op 

- antibiotics

- consider specific Propionobacterium cover

- assess ER pre-operatively

 

Position

 

1.  Beach-chair position

- McConnell head rest

- patient at table edge / removable edge

- shoulder must overhand table

- allows GHJ extension

- need this to insert stem

- 500 ml saline bag between shoulder blades

 

2. T-max table with Spyder attachment

 

Incision / Dissection

 

Extended deltopectoral approach

- coracoid to deltoid insertion 

 

Separate deltoid & pectoralis major

- retracting cephalic vein laterally causes less bleeding

- retracting cephalic medially prevents cephalic avulsion from subclavian vein

- place Cobell retractors under deltoid

 

Deep dissection

- divide clavipectoral fascia on lateral edge conjoint

- elevate conjoint, feel for MCN

- replace medial retractor blade under conjoint tendon

- ER humerus and expose SSC

 

Exposure

- blunt dissect subdeltoid space

- right up to coracoid and clavicle

 

Open Approach Shoulder

 

Dangers

 

1.  Musculocutaneous nerve

 

Branch lateral cord

- penetrates coracobrachialis 3-8 cm distal to coracoid

- beware rare cases higher

- palpate MCN under conjoined tendon

- place finger under tendon and sweep downwards to palpate

 

Average 3 cm

- most common cause of damage = overzealous retraction

- avoid release of conjoined tendon if possible / protects MCN

 

2.  Axillary nerve

 

Terminal branch of posterior cord

- arises inferior to coracoid

- crosses anteroinferior border of subscapularis muscle

- exits quadrangular space with posterior circumflex humeral artery

 

Palpate

- slide finger under conjoint tendon

- run downwards over SSC muscle

- hook finger anterolaterally to feel nerve

- relatively tight cord running posteriorly

- relatively protected with adduction & ER

 

Tug test

- palpate anterior axillary nerve under anterior deltoid

- tug on axillary nerve over SSC

- will feel the nerve moving back and forth

- ensures is intact at end of operation

 

Quadrangular space

- below SSC anteriorly / T minor posteriorly

- inferior is T Major posteriorly

- between long head triceps and SNOH

 

Splits into 2 trunks 

1. Posterior to teres minor & posterior deltoid

- terminates as superior lateral cutaneous nerve

2. Anterior passes to middle then anterior deltoid 

 

Releases / Exposure

 

1.  Coraco-acromial ligament

- place fang retractor on coracoid

- don't divide in full or risk superior escape of humeral component

- take anterior triangle with diathermy

- aids exposure

 

2.  Pect Major insertion

- divide upper 50%

- can release more if needed, but repair at end

- allows ER of humerus

 

Ligate Anterior Circumflex Humeral blood vessels

- 3 sisters

- at inferior SSC tendon

- can tie off with stay sutures

 

Identify rotator interval

 

3.  Identify and release biceps

- divide biceps at insertion with scissors

- perform tenodesis later

 

Feel and palpate supraspinatous / infraspinatous

- ensure that are intact

- otherwise repair / change to reverse TSR

 

4.  Release Lat Dorsi / Teres Major if needed

- ER humerus

- subperiosteal dissection with diathermy

 

5.  Clavicle osteotomy

- if exposure difficult

- revision / large muscular men

- divide fascia to expose clavicle

- anterior 1/3 of clavicle

- from ACJ (don't violate) to anterior curvature of clavicle

- complete with saw / osteotome

- repair with sutures at end of case

 

6.  Can release conjoint tendon if needed

- usually via coracoid osteotomy

- predrill

- secure with screw later

 

SSC options

 

A. Divide SSC tendon

 

Advantage

- easy to do

 

Disadvantage

- tendon - tendon healing less reliable

- need to protect ER post operatively

- high incidence of SSC failure / poor lift off test

 

Technique

- want to leave long

- so don't limit ER when repairing

- insert medial 2.0 vicryl stay sutures

- take vertically right on insertion on LT

- take entire tendon plus capsule

- will repair through drill holes at end of procedure

 

B.  LT Osteotomy

 

Advantages

- bone to bone healing much more reliable

 

Technique

- expose inferior humeral flare

- don't want inferior cut venturing into humeral shaft / is a fracture risk

- release inferiorly

- pass ring handled spike behind the SSC
- IR humerus to neutral

- use oscillating saw

- begin in intertubercular groove

- aim to exit deep rather than shallow

- don't want saw exiting in SSC

- if take cartilage can simply excise with nibblers

- usually small 2 cm oval piece

- place ethibond stay sutures

 

Humeral Osteotomy

 

Release

- soft tissue off inferior neck of humerus

- ER humerus to put tissues on tension

- use osteotome to remove beard osteophytes

- may need to release lat dorsi and teres major tendon

- release capsule anteriorly 12 to at least 6 O'clock from humerus +++

- stay on bone

 

Deliver humeral head

- Extend & ER humerus to dislocate

 

Identify true anatomical neck

- aided by removal of crown osteophytes

- saw blade should exit at superior and inferior edge of articular cartilage

- this is the osteotomy site

 

Cut in planned retroversion

 

Usually 25o of retroversion

- can match to patient's own retroversion

- i.e. osteotomy removes cartilage front and back

- can reduce retroversion if large amount of glenoid retroversion present

 

Varus / valgus 130° to long axis

 

Technique 1

- flex elbow

- use forearm as protractor

- ER forearm 25o

- cut directly posteriorly

 

Technique 2 (Global)

- use jig

- insert humeral reamers (long and straight)

- up to templated size

- attach jig to humeral reamer

- set one part of jig aligned to the forearm as reference

- dial in required retroversion

- set height of desired cut

- pin in situ

 

Use oscillating saw

- insert retractors to protect glenoid / infraspinatous /supraspinatous

- surprisingly small amount of bone removed

 

Remove humeral osteophytes

- anterior crown / often best with osteotome directed superior to inferior

- fully ER head and remove posterior neck osteotophytes

 

Stem

 

Deliver proximal humerus

 

Insert broach

- has fins to ensure correct rotation of prosthesis

- insert trial stem

- also have head caps

- leaving the stem in prevents fractures

- leaving cap on prevents crushing cancellous bone

 

Surface Replacment / No stems

 

May have improved outcome

- recreate anatomy including version

- stem does not dictate head placement

- very difficult to overstuff joint

 

Glenoid Releases

 

Glenoid Releases

 

Very important for the exposure

 

SSC releases

 

Use to be 360o release

- fatty infiltration post operatively was identified on MRI

- thought to be due to denervation anteriorly

 

180o release

- use stay sutures to pull SSC laterally

- posteriorly identify capsule interval

- divide capsule along posterior SSC (MGHL and IGHL)

- completely elevate from anterior glenoid

- superiorly identify CHL and divide

- use finger to free SSC superiorly and posteriorly right along scapula

- should now be able to mobilise SSC freely

 

Divide inferior capsule

- palpate axillary nerve

- place retractor over AXN

- divide capsule along inferior glenoid to 6 o'clock

 

Resect

- biceps insertion

- labrum

- MGHL

 

SSC

- push medially

- protect with sponge

- retract with fang retractor

 

Release anteriorly

 

Release inferiorly

- often more important for reverse TSR

- use cobb to elevate inferior capsule

- divide long head of triceps if needed

 

Continue humeral neck release

- release around neck all the way to posterior

 

Glenoid Exposure

 

TSR Glenoid Exposure 1TSR Glenoid Exposure 2

 

Need a straight shot at the glenoid

 

Humerus

- flexed

- head pushed posteriorly

- IR

 

Retractors

- on posterior lip of glenoid

- retractor displaces head posteriorly

- Fukuda retractor / Fang

 

Allow for stress relaxation to occur

 

Danger: Glenoid Fracture

 

Inferior retractor to protect axillary nerve
- above inferior capsule

- bunny ears / playboy retractor

 

Additional Techniques

- elevate patient's bed / drops arm

- tilt patient ipsilateral side up

 

Assess glenoid

 

Often posterior erosion

- OA may be due to subtle posterior instability

 

Posterior erosion options are

 

1.  Lower anterior rim 

- recreate version

- remove anterior half with reamer

- maximum 10o

 

Problem

- removing bone stock which is limited

- reduce vault and increase risk of vault penetration

- increase risk of difficulty seating glenoid

- medialise glenoid component

- there are no increased poly thicknesses

 

2.  Decrease humeral retroversion

- resect head with arm in < 25o ER

 

3.  Bone graft posteriorly

- use napkin ring femoral neck allograft thicker posteriorly

 

4.  Custom component with post wedge build up

 

Insert Glenoid Component

 

Glenoid options

 

1.  Cemented all poly curved back

- most common, best results

 

A.   Peg v central keel

- pegs may be single or multiple

 

B.  Flat v curved back

- curved backs may seat better

 

C.  Cementing

- trend now to minimize cement behind poly (place only in plug holes)

- this is because can get a very thin film of cement which can crack

- however, demonstrated increased pullout strength with increased cement thickness

 

2.  Uncemented metal back

- secured with screws

- advantage is can be same prosthesis as in reverse

- i.e. can convert later to reverse if failure of cuff

- problem is continued issues with metal / poly interface

- also problems with overstuffing

- higher rate of revision

 

Centre peg crucial

 

Vault is a triangle

- pilot hole critical

- must not penetrate vault

 

Direction

- usually slightly superior in TSR to equator

- if put glenoid too low the humeral head will ride high

- need to match tilt as well as version

 

"Glenoid Centering Point" (Matsen) 

- index finger anterior to glenoid palpates centering point in sulcus 

- bounded by upper & lower crura of scapula & flare of glenoid vault 

- 6-8 cm medial

- wire should exit anteriorly at this point

 

Hypoplasia

- glenoid is sufficient size if can take central peg

 

Technique

- insert guide pin

- gently ream central peg

- check intact cortex with arthroscopy probe

 

Vault blowout

- i.e. any drill hole comes out of vault

- especially important for central peg

- loose pressurisation of cement

 

TSR Central Peg BreachTSR Glenoid Vault Breach

 

Solution

- insert bone graft

- pressurise only intact holes

 

Cement Glenoid

 

TSR Cemented Glenoid APTSR Cemented Glenoid Lateral

 

Remove labrum

- allows sizing and correct orientation of glenoid

 

Trial size

- place trial

- ream central peg where you want it

 

Insert reamer

- take off cartilage

- can eccentrically ream if needed

 

Insert new broach

- ream for other pegs if needed

- three or five

 

Keep holes dry

- insert sponge

 

Insert cement into peg hole

- use syringe

 

Insert Poly

- pressurise

 

Head

 

Overstuffing of joint causes poor ROM

 

1.  Height

- head sits only 3 mm above GT

- too high places excessive stress on RC

 

2.  Size

- small enough to close SSC

- too large a head limits ROM & increases risk of SS and SSC rupture

 

3.  Offset heads

- normal head offset from neck posteriorly and medially

- placing head more anterior than normal increases strain on cuff and glenoid

- i.e. can anteriorly impinge on SSC and cause late rupture

 

Trial

 

Should be able to

A.  Inferiorly sublux head 50% glenoid

B.  Posteriorly sublux head 50% and return to centre

C.  Able to close SSC without impingement on head

D.  Close SSC with arm in ER 30o

E.  Place hand on chest

 

Insert stem

 

A.  Cemented

- don't pressurise

- can crack stem

 

B.  Uncemented

- very good results

 

Posterior Instability

 

1.  Posterior capsule plication

- lamina spreader between stem and glenoid

- place east - west sutures / 3 x horizontal ethibond sutures

 

2.  Place sutures in capsule posteriorly

- run ethibond anteriorly through joint

- tie to conjoint tendon

 

3.  Place arm in ER post operatively

- de-tensions posterior capsule

- allows capsule to scar

- i.e. gunslinger position

- also keeps humeral head forward

 

Closure

 

A. Reattach SSC via drill holes in anterior neck of humerus

- insert sutures prior to cementing stem

- 5 x drill holes

- 4 x 5 ethibond

- place arm in 30o ER

- pass in horizontal mattress suture through SSC edge

 

B.  LT osteotomy

- lateral drill holes in humerus

- suture through drill holes and medial to LT into SSC

- this can tend to lateralise LT, limit ER

- various techniques to avoid this

- can pass sutures about stem

 

Biceps tenodesis

- suture usually

 

TSR0001TSR0002

Total Shoulder Replacement

IndicationsTSR All Poly Glenoid

 

RA 

OA 

AVN 

 

Contra-indications

 

Infection

Charcot

Paralysis of deltoid

Torn rotator cuff

Insufficient glenoid bone stock

 

Requirements

 

1.  Functioning / Repairable rotator cuff

- maintain stability

- maintain centre of joint rotation

- early failure if cuff deficient

 

TSR plus cuff repair

 

2.  Intact Deltoid

 

3.  Resonable glenoid bone stock

- commonly posterior bone loss in OA

- glenoid component must be completely supported by peripheral bone rim or early failure

- beware glenoid hypoplasia

 

Anatomy

 

Glenoid

 

Height

- 35 - 40 mm

 

Width

- approximately 70% glenoids are pear shaped

- remainder elliptical

- upper width average 23 mm

- lower width average 29 mm

 

Shoulder CT Glenoid OvalShoulder Glenoid CT Pear Shaped

 

Inclination

- approximately 4 - 5o superior

 

Version

 

Healthy shoulders

- mean 2o anteversion

- large range

- 14o anteverted to 10o retroverted

 

Pathology

- RC 8o retroversion mean

- OA 15o retroversion mean

- RA 15o degrees retroversion mean

 

Vault

 

Usually triangular

 

Scapula

 

30o anteverted from coronal plane

 

Humeral head

 

Retroversion 30o

 

Design

 

Constraint

 

Highly

- never used

- high failure rates / peri-articular fracture

 

Semi Constrained

- cupped glenoid

 

Unconstrained 

- GE > 90%

- most common design 

 

Stem

- cemented v uncemented

- stems v resurfacing

 

TSR No StemTSR Uncemented StemTSR Cemented Stem

 

Glenoid

- metal backed

- all poly

 

TSR Metal Backed Glenoid

 

Planning

 

AP XR IR & ER 

- Assess head

 

Axillary 

- Assess glenoid

- OA = Posterior bone loss

- RA = Medial bone loss  / protrusio

 

Template

 

1.  Stem

- size

 

2.  Head

- neck osteotomy

- head diameter and depth

 

3. Glenoid size

 

CT

 

1.  Assess bone stock

- sufficent bone in glenoid

- exclude glenoid hypoplasia

 

CT TSR Preop Glenoid CystsTSR Glenoid CT Good Bone StockTSR CT Glenoid Good Bone Stock

 

2.  Assess version / posterior deficiency

 

Measurement

- can be suprisingly inaccurate

 

Hoenecke JBJS 2010

- 2D CT depends on angle CT gantry

- 20% error > 10o

- 3D CT best

 

Normal

- average is 2o anteversion

- up to 15o retroversion can be normal

 

Options for Management Glenoid Version

 

A.  Neutral inclination glenoid

- reduce retroversion of head to 25o

 

TSR Glenoid CT Neutral Inclination

 

B.  0 - 10o retroversion of glenoid

 

Plan

- alter with reaming / 10o change is the maximum

- otherwise can run into difficulty seating glenoid

- reduce retroversion of head further

 

TSR Glenoid CT Mild Retroversion

 

C.  20o + retroversion of glenoid / deficiency

 

Options

- alter up to 100 with reaming

- reduce further the retroversion of head

- glenoid bone augments / augmented poly

- may require primary glenoid osteotomy

 

Glenoid Posterior Deficiency.jpgGlenoid Posterior Version and Deficiency

 

Assess Rotator Cuff

 

MRI

Ultrasound

 

Rehabilitation

 

Neer's 3 Phase shoulder rehabilitation

 

Phase 1 Passive motion in forward flexion & ER

Phase 2 Active Assisted 6-8 weeks 

Phase 3 Advanced muscle strengthening 3/12

 

Results

 

1.  Pain

 

Pain relief good 90%

 

2.  ROM

 

Range of motion variable

- OA with intact cuff = 120° elevation

- Post fracture or huge cuff tear = 40°

 

ROM gain

- OA 77o

- RA 57o

- post trauma 33o

 

3.  Survival

 

Deshmuhk et al J Shoulder Elbow Surg 2005

- 93% survivorship 10 years

- 88% 15 years

- average age 60 years

- mostly Neer II prosthesis

 

Sperling et al J Shoulder Elbow Surg 2004

- patients under 50 having TSR (Neer II)

- 97% 10 years, 84% 20 years

 

Complications

 

1.  Subscapularis Failure

 

Causes

- poor reattachment

- overstuffing anteriorly

- humeral anteversion

- denervation

 

Prevention

- trial ER on table at end

- limit rehab to this

 

Consequences

- decreased ROM

- pain

- instability

 

Salvage

1.  Re-repair - limited success

2.  Pectoralis major transfer

- results poor in shoulder arthroplasty

- Jost et al JBJS Am 2003

3.  Achilles tendon bone allograft

4.  Bristow

5.  Reverse

 

Loosening

 

TSR Loose glenoidGlenoid Component Loosening

 

Rates

- 5-40%

- clinical loosening relatively infrequent

- uncemented > cemented

 

Glenoid lucent lines 

- relatively common 

- ~ 30-96%

- not all are associated with pain

- not all require revision

 

Humeral component

- loosening rare

 

Instability 5%

 

Anterior  

 

Cause

- mal-rotation humeral component most common

- subscapularis rupture

- anterior deltoid dysfunction

- glenoid component loosening

 

TSR Anterior Instability LateralTSR Anterior Instability AP

 

Superior  

 

Cause

- attenuation cuff or frank rupture

- dynamic muscle dysfunction

 

Prevention

- must ensure don't leave humeral head proud

- restore shenton's line

- results in eccentric loading of glenoid component & loosening 

- "rocking horse glenoid"

 

Shoulder Hemiarthroplasty Rotator Cuff FailureTSR Superior Escape

 

Posterior (most common problem) 

 

Cause

- excess retroversion of glenoid or humerus

- posterior glenoid erosion

- ST imbalance

 

TSR Posterior DislocationRevision for Posterior Dislocation TSR Combined Anterior Posterior Approach

 

Management

- may need posterior approach to reduce

- allows posterior capsular plication

- alter component version / increase anteversion

- anterior releases

 

Inferior  

- especially post fracture with shortening of humerus

- important to re-establish humeral length to restore resting tension of cuff & deltoid

- overstuffing of joint

 

Post-op rotator cuff failure

 

Rate

- 2%

 

Cause

- due to head malplacement or malposition

- respond poorly to reconstruction

 

TSR Failed Rotator CUff

 

Management

- revise to reverse TSR

 

Peri-prosthetic Fracture

 

Type

A:  Tip of prosthesis with proximal extension

B:  Fracture at tip only

C:  Fracture distal to tip and extends into distal metaphysis

 

Options Humeral Shaft Fracture

 

A.  Non operative Management

- prothesis stable

- acceptable aligment

 

B.  ORIF

- anterolateral approach and plate

 

C.  Revise to long stem > 2 cortical diameters past fracture

 

TSR Humeral Fracture TSR Humeral Fracture United

 

Results

 

Kumar et al JBJS Am 2004

- 16 patients

- 6 healed after 180 days of non operative treatment

- 5 required operation after 123 days non operative treatment

- recommended all fractures can be treated non operatively

- if well aligned and prosthesis stable

- if not united by 3 months, recommend intervention

 

Infection 1%

 

TSR Infected

 

NV injury

 

AXN / MCN

  

Ectopic Ossification

Arthroscopy

Position

 

1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape

 

Lateral Decubitus Shoulder ArthroscopyShoulder Arthroscopy Lateral DecubitusShoulder Lateral Decubitus Arthrex

 

2.  Beachchair

 

A.  Beachchair table

- pillow under thighs

- arm draped free

- access to posterior shoulder

- head secured to Mayfield head ring

 

B.  Spyder / Tmax

- holds head secure

- good access to posterior shoulder

- hydraulic arm holder elminates need for assistant to hold arm

 

Shoulder Arthroscopy TmaxShoulder Arthroscopy Spyder

 

Portals

 

Shoulder Arthroscopy Portals

 

Posterior Portal

 

Shoulder Arthroscopy Posterior Portals

 

Main portal for arthroscopy

 

A.  Soft spot

- identify posterolateral acromion

- 2 cm medial & 2 cm inferior

- through deltoid

- between infraspinatous and T minor

 

Make stab wound at post portal

- introduce cannula & trocar

- tip towards coracoid process

- distract shoulder joint whilst inserting

- introduce arthroscope

 

B.  Variation

- if mainly performing subacromial / rotator cuff

- move portal lateral and superior

- 1 cm inferior and 1 cm medial to posterolateral acromion

- aims scope over cuff tear which is usually lateral

- increases distance from cuff vertically

- can view larger area

 

Additional portals

 

Anterior Glenohumeral Portals

 

Arthroscopy Anterior PortalShoulder Arthroscopy Portals Anterior

 

Rotator Interval

- biceps, glenoid & humeral head form a triangle with subscapularis in the base

- place anterior portals in this triangle above subscapularis, lateral to coracoid

 

Shoulder Arthroscopy Rotator IntervalRotator Interval

 

A.  Retrograde method

- direct scope into rotator interval

- advance until rests against anterior capsule at superior edge subscapularis

- light transilluminates skin at site of portal

- ensure lateral to coracoid

- remove scope from sheath

- insert Wissinger rod / switching stick through sheath

- make stab incision

- advance rod

- insert cannula over stick

- use portal for probe & instruments

 

B.  Direct / anterograde

- insert 19 gauge spinal needle

- always lateral to coracoid

- pass into rotator interval

- stab incision / switching stick / cannula

 

Anteroinferior portal

- just above SSC

- angle to get to anterior labrum / bankart repair

- 3 - 6 o'clock

 

Shoulder Scope Low Anterior Portal

 

Anterosuperior portal

- high in rotator interval

- in angle between humeral head and biceps

- working portal for suture exchange in stabilisation surgery

- good angle for anchor insertion for SLAP repair

 

Anterosuperior Glenohumeral portal

 

Posterior Portal

 

Technique

- insert switching stitch through camera cannula

- insert camera through anterior cannula

- pass cannula over switching stick

 

Uses

- inspect / probe / repair posterior portal

 

Shoulder Arthroscopy Posterior Portal

 

Posterolateral portal

 

For posterior labral tears

- inferior and lateral to posterior portal

- allows placement of the inferior anchor

 

Shoulder Posterior Portals 1Shoulder Posterior Portals 2

 

Posterior Subacromial Portal

 

Redirect posterior cannular with blunt trochar

- remove camers

- direct it superiorly immediately below acromion once through deltoid

- sweep trochar laterally to break adhesions

 

Lateral Subacromial portal

 

Working portal

- for subacromial decompression / ACJ resection / RC surgery

- 2 - 3 cm lateral to lateral acromion

- 1 - 2 cm posterior to anterior acromion

- usually in line midportion / posterior border of clavicle

- insert needle

- should be above cuff, below acromion

- parallel to acromion

 

Anterosuperiorlateral Portal / Port of Wilminton

 

Shoulder Scope Port WilmingtonShoulder Scope Port Wilmington 2

 

Indication

- SLAP

- passes through supraspinatous

- anterolateral border acromion

- can place more posteriorly to access posterior aspect of SLAP

- in this case will pass through infraspinatous

 

Superior portal Neviaser / Superomedial portal

 

Indication

- access posterior SLAP / decompress suprascapular nerve

- pass through RC / supraspinatous

- 1 cm medial to acromion

- 1 cm posterior to clavicle

 

Fluid

 

A.  Pressure pump

- usually 40 - 50 mmHg

- can temporarily increase if required

 

B.  Adrenaline in bags

- 1 mg in each 3L bag

 

Examination of GHJ

 

Systematic Approach

 

A.  Glenoid medial / Humeral head lateral

- arthritis / chondral damage

 

Arthroscopy Humeral Head OAGlenoid OA Arthroscopy

 

B.  Biceps

- careful examination / probing of insertion

- examination of intra-articular portion for degeneration

- pull extra-articular portion into joint to confirm gliding well

 

Arthroscopy Normal Biceps InsertionArthroscopy Normal Biceps TendonArthroscopy Normal Biceps Tendon 2

 

C.  Labrum

- 360o examination

- anterior / inferior / posterior

 

Arthroscopy Normal Anterior LabrumShoulder Arthroscopy Inferior LabrumShoulder Arthroscopy Posterior Labrum

 

D.  Glenohumeral ligaments

 

Superior

 

Superior Glenohumeral Ligament

 

Middle

- crosses subscapularis vertically

 

MGHL Arthroscopy

 

Inferior / anterior aspect of IGHL

- attachment to labrum between 3 and 6 o'clock

- look down into inferior recess

- see attachment to inferior humerus

- exclude HAGL / exclude loose body

 

Arthroscopy Normal IGHL Humeral InsertionNormal IGHL Glenoid AttachmentShoulder Loose Body

 

E.  Rotator Cuff

 

Subscapularis

- examine insertion

- ER the humerus

 

Arthroscopy Normal SubscapularisSubscapularis Normal Arthroscopy

 

Supraspinatous

- examine underside and insertion

- abduct and ER

- should be no gap between cartilage and insertion

 

Supraspinatous Normal ArthroscopySS normal arthroscopySupraspinatous Tendon Normal Crescent Variant

 

Infraspinatous

- insertion at posterior humerus next to bare area

- Hill Sach's lesion (has cartilage each side c.f. bare area)

 

Shoulder Arthroscopy Infraspinatous Insertion

 

Neurological Complications

 

Uncommon (0.1%)

 

1. Posterior Portal

- if placed inferiorly can damage AXN below Teres minor 

 

2. Anterior Portal

- damages MCN if medial to coracoid

- brachial plexus & axillary artery

Clavicle

Clavicle Fractures

Clavicle Fracture Displaced

Mechanism

 

Usually a direct blow 

- less commonly a fall on the outstretched hand

 

RTA / sporting accidents commonest causes

 

Can be pathological as a result of radionecrosis

- eg following radiotherapy for breast cancer.  

 

Incidence

 

Fractures of the clavicle are common

- 5% of all fractures

- Up to 80% involve the middle third

 

Anatomy

 

Ossification

 

First bone to ossify in 5th week of foetal life

- intramembranous ossification

- medial growth plate accounts for 80% length

- medial physis last to close at 22-25 years

 

Shape

 

The middle third of the clavicle is the junction of two curves

- medial convex anteriorly 

- lateral convex posteriorly  

 

At the junction there is little cancellous bone

- skeletal muscle covers only part of the cortical bone

- the volume of muscle in this region is small

 

The clavicle is secured firmly at each end by stout ligaments and joint capsules

 

Movement

 

It rotates approximately 40o when the scapula is elevated

- most of the rotation occurring after the arm passes the horizontal level 

 

Classification

 

Fractures may be divided into three regions of the clavicle 

 

Medial end

- fifth of the bone

- lying medial to a vertical line drawn upward from the center of the first rib 

- rare

- <5%  

 

Lateral clavicle fracture

- fifth of the clavicle

- lateral to a vertical line drawn upward from the center of the base of the coracoid process

- a point marked by the conoid tuberosity

- approximately 1/3 of all clavicle fractures 

 

Diaphysis 

- intermediate three-fifths between these two areas 

- most common

- 70% of clavicle fractures

 

Clavicle Diaphysis Fracture

 

Examination

 

Examine skin

- ensure skin not threatened by spike of bone

 

Examine AXN

- sensation in deltoid patch

 

Look for scapula winging

- may be an indication for fixation

 

Xray

 

Clavicle Midshaft Displaced

 

Displacement

- the proximal end under the pull of SCM becomes elevated

- the shoulder tends to sag downwards and forwards

- with further displacement there is overlapping and shortening 

- the portions of the clavicle may also be rotated relative to one another

 

Non Operative Management

 

Sling for comfort

- followed by early mobilisation as the pain subsides

 

Figure of 8 bandage 

- these do not effectively reduce the fracture 

 

Complications Non Operative Management

 

1.  Persistent bony spike

- even after normal remodelling

- may require excision

 

2.  Thoracic outlet syndrome

- secondary to hypertrophic non-union of the clavicle

- also due to reduced subclavicular space in a shortened malunion

- late compression of ulna nerve, brachial plexus

- symptoms with overhead activities

 

2.  Non union 

 

Clavicle Non UnionClavicle Nonunion

 

 

Neer (6) 1960 JAMA

- 2235 closed clavicle fractures treated non-operatively

- non union in only 3 (0.1%) 

- his series of 45 fractures treated by open reduction, there was non union in 2 (4%)

 

Rowe Clin Orthop 1968

- nonunion in 0.8% of fractures treated by closed methods

- 3.7 % in those treated by open reduction

 

Robinson et al JBJS Am 2004

- prospective cohort study

- overall non union rate in clavicle fractures of 6.2%

- 4.5% of diaphyseal fractures / 11.5% lateral fractures / 8.3% medial fractures

- factors increasing risk non-union in diaphyseal fractures

- advancing age / female gender / complete displacement / comminution

 

3.  Malunion

 

Clavicle Fracture Shortened and Displaced

 

Hill et al JBJS Br 1997

- studied 52 completely displaced midshaft clavicle fractures

- all treated non operatively

- 8/52 (15%) developed non union

- 16/52 (31%) unsatisfactory (residual pain / brachial plexus symptoms)

- initial shortening of > 20 mm associated with non union and poor outcome

 

McKee et al JBJS Am 2003

- poorer functional outcome

- fractures > 2cm shortening

 

Clavicle Fracture Shortened

 

Canadian Orthopedic Trauma Society JBJS Am 2007

- multicentred RCT of op (62) v non op (49) treatment displaced midshaft clavicles

- 1 year followup

- average time to radiographic union 28 v 16 weeks

- non unions 2/62 v 7/49

- symptomatic malunion 0/62 v 9/49

- better shoulder scores at all times

- in operative group, 3 wound infections, 1 mechanical failure and 5 prominent hardware

 

Operative Management

 

Absolute indications 

 

Skin compromise (open fracture or severe skin tenting)

Neurovascular injury

 

Clavicle Fracture Skin Tenting

 

Open Clavicle Fracture

 

Relative indications

 

Floating shoulder 

Multi-trauma

High risk of non union / malunion

Non union

 

1.  Plate fixation

 

Clavicle PlateClavicle Plate

 

Indications

- fresh fractures of the middle third 

- gross displacement and angulation of the bone 

- shortening of the clavicle that was estimated to exceed 2.5 cm on plain radiographs

 

Results

 

Bostman et al J Trauma 1997

- plate fixation (DCP / Pelvic Recon)

- ORIF in 103 (9.5%) of the total of 1081 patients

- complication rate 23% 

- infection rate was 7.8%

- both patients treated with a 1/3 tubular plate suffered plate breakages

- 10 patients required reoperation for loosening, infection, non union or plate breakage (10%)

 

Technique

 

Lazy beach chair

- square drape

- LA with Adrenalin

 

Transverse incision in Langer’s line

- can make incision inferior to clavicle

- pull it up, keeps wound away from plate

- can identify and protect supraclavicular nerves

- divide platysmus as a layer to repair later

- clean and reduce fracture

- application contoured locking plate

- need 6 cortices each side

 

Complications

- infection

- numbness infraclavicular (tends to reduce in size)

- non union

- hardware failure

- arterial injury

- pneumothorax

 

2.  IM Screw 

 

Clavicle IM Fixation

 

Results

 

Boehme et al 1991 JBJS Am

- 21 patients established symptomatic non union

- intramedullary Hagie pin

- autologous bone grafting

- 20/21 union

- average time to healing of twenty-two weeks (range, twelve to thirty weeks)

- 17 / 21 the screw had to be removed due to development of a tender bursa

 

Technique

 

Open approach to fracture

- 2 - 3 cm

- hand drill medially 

- pass cannulated wire laterally and out through skin

- reduce fracture, retrograde pass wire medially

- drill lateral fragment

- insert cannulated 7.3 mm screw

- needs to be between 80 and 110 mm

- check x-ray to ensure good medial fixation

- BG if non union

 

Post op

- limit ROM above shoulder height for a period

- decreases rotational forces and reduce risk of non union

 

3.  External Fixation 

 

Indications

- open fractures 

- severely displaced fractures with damaged skin

 

Technique

- medial pins are anterior to posterior in an ascending direction to avoid the pleural dome

- lateral pins are superior to inferior in an almost vertical direction 

 

4.  Management Malunion

 

Clavicle Malunion ORIF

 

Results

 

McKee et al JBJS Am 2003

- 15 patients mean age 37 years over 4 year period

- average shortening 2.9 cm

- complaining of pain and fatigueability

- also complaining of symptoms consistent with thoracic outlet syndrome

- many complained of cosmesis

- patients had scapula winging

- osteotomy and DCP (no bone graft required)

- 1 non union

- 8/12 patients with weakness and pain improved

- neurological symptoms eliminated in 7, decreased in 3, unchanged in 1

Lateral Clavicle Fracture

Epidemiology

 

Elderly population

Less common in younger population

 

Lateral 1/3 Neer Classification

 

Type I

 

Lateral Clavicle Fracture Undisplaced

 

Fracture lateral to the CC ligaments

- does not extend into the ACJ

- non displaced

- most common 4:1

 

Type II

 

Lateral Clavicle Fracture

 

2A

- medial to CC ligaments

- CCL ligaments attached to lateral fragment

- medial fragment displaced superiorly

- highest rate of non union

 

2B

- between conoid and trapezoid

- conoid disrupted

- trapezoid remains attached to the lateral fragment

- more stable

 

Type III

 

Involves articular surface ACJ

- ligaments intact

- may present as late degenerative change

 

Type IV

- skeletally immature patient

- paediatric sleeve fracture

- ligaments attached to periosteum

- displacement of proximal fragment

 

Non Operative Management

 

Robinson JBJS Am 2004

- cohort of 100 displaced Type II fractures

- 20% asymptomatic non-union

- 14% of cohort required surgery

- recommended non operative treatment in middle aged / elderly

 

Operative Management

 

Operative Indications 

- Compound / skin compromise

- displaced fracture in young people

- non union

 

Options

 

1.  Dorsal plate / locking wrist plate

 

Lateral Clavicle Plate

 

Case 1

 

Lateral Clavicle ORIFLateral Clavicle ORIF 2

 

The lateral clavice fracture has been cleaned and reduced

- held with K wire across ACJ

- high strength suture around clavicle and coracoid

- locking plate applied, reinforced with IM screw, and high strength tape around coracoid

- advantage: no need to remove hook plate

 

2.  Hook Plate

 

Lateral Clavicle Fracture Hook Plate PreopLateral Clavicle Fracture Hook Plate Post op

 

Halder et al J Should Elbow Surg 2006

- 22 patients treated with hook plate

- very limited ROM (90o flexion) until plates removed at 3-4 months

- 1 disengaged from acromion (should have used acromial screws)

- 1 disengaged from clavicle (should have used 6 not 4 hole plate)

- 1 clavicular fracture at end of plate

- 1 non union, 1 delayed union

- 1 infection

- most complications in patients > 60

 

Hook Plate Disengage

 

3.  Endobutton

 

Robinson et al JBJS Br 2010

- 16 patients under 60 with displaced type 2

- all treated under 3 weeks

- endobutton in coracoid, clavicle reduced, endobutton clavicle

- 1 symptomatic non union

 

Non Union

 

Lateral Clavicle Non unionLateral Clavicle Nonunion ORIF

 

Distal clavicle nonunionDistal Clavicle Nonunion

 

Options

 

1.  Bone graft / ORIF

 

2.  Excise

- open

- arthroscopic

 

Floating Shoulder

Definition

 

Combination of scapular neck fracture and ipsilateral clavicle fracture / CC ligament disruption

 

Imaging

 

Floating Shoulder

 

Floating Shoulder 1Floating Shoulder 2

 

Glenoid Neck Fracture CTClavicle Fracture CT

 

Epidemiology

 

High velocity injuries

- MVA

- MBA

 

Fractures usually of scapular neck

 

Potential Problems

 

Disrupts the suspensory mechanism of the shoulder

- displacement disrupts normal stability of GHJ

- changes biomechanics

- subacromial pain / impingement

 

NHx

 

Little evidence

- concern with displacement of fractures

- weakness of abduction / subacromial pain / poor shoulder function

- risk of non / malunion

 

Used to be recommended surgery for floating shoulder

 

Non operative Management

 

Indication

- undisplaced fractures

 

Edwards et al JBJS Am 2000

- 20 patients with floating shoulder treated non operatively

- 11 with displaced clavicle fractures (>10mm)

- 5 with displaced scapula fracture (>5mm)

- 19/20 united (one had segmental clavicle bone loss from gunshot)

- excellent functional scores

 

Labler J Trauma 2004

- 8 treated non operative, 9 treated operative

- 5 good results in each group

- recommend nonoperative treatment for less displaced fractures
 

Egol et al JBJS Am 2001

- 19 patients with clavicle fracture and displaced fracture glenoid neck

- 12 non operative, 7 operative

- good results in each group

- recommend individualized treatment

 

Operative Management

 

Options

 

1.  ORIF clavicle

 

Minimally displaced glenoid fracture

 

Floating Shoulder Clavicle ORIF

 

2.  ORIF glenoid and clavicle

 

Displaced scapular neck

- > 40o angulation

- > 1cm displacement

- CT useful

 

Leung et al JBJS Br 1993

- 15 patients floating shoulder

- all scapular neck

- ORIF clavicle + glenoid (posterior approach)

- good functional outcome in all patients

 

Note:

- risk of PTX during surgery if rib fracture (secondary to PPV)

- may need chest tube

 

Rib Fracture CT

Frozen Shoulder

Definition 

 

Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 

 

Epidemiology

 

2% incidence

- 40 - 60 years

- Women 2:1

 

Sedentary workers

- Non-dominant limb

 

Bilateral in 10 - 40%

 

Aetiology

 

Primary

- Unknown

- ? Autoimmune theory

 

Associations 

- diabetes - 35% IDDM > 10yrs

- yhyroid disorders

- stroke

- MI

- cardiac surgery

- neurosurgery

- dupuytren's

 

Not Associated with

- OA

- Cuff Pathology

 

Secondary

 

Intrinsic

- post surgery i.e. RC

- trauma i.e. SNOH, stabilisation

- immobilisation

 

Extrinsic

- cervical radiculopathy

- axillary node clearance

- long period immobilisation

 

Classification Neviaser

 

Each lasts 4-8 months

 

1.  Freezing

- painful stage

- capillary proliferation, synovial hypertrophy

- develop capsular adhesions

 

Shoulder Arthroscopy Frozen Shoulder

 

2.  Frozen

- decreasing pain, increasing stiffness

- maturation and development capsular contractures

 

3.  Thawing

- decreasing stiffness

 

Pathology

 

Neviaser described pathology of frozen shoulder 

- contracture of capsuloligamentous structures

- inflammation followed by fibrosis

 

Cellular basis poorly understood

- a dense matrix of type 1 and II collagen

- laid down by fibroblasts and myofibroblasts

 

1° Frozen Shoulder

 

Initial synovitis of unknown cause results in

- intra-articular adhesions

- capsulitis

- obliteration of inferior axillary fold

 

Subsequent development of

- subacromial adhesions

- rotator cuff contracture

 

Eventually spontaneous resolution

 

2° Frozen Shoulder

- much less synovial inflammation

- 2° due to either intrinsic or extrinsic cause

 

Natural History

 

Traditionally thought to be benign & self-limiting

 

Grey 1978

- 24/25 resolved by 2 years 

- Maximum 10 years

 

Most have no significant symptoms or functional restriction

- But not as benign as previously thought

 

Reeves 1975

- 60 % have residual decreased ROM 

- usually limitation ER

- only 6% claimed functional disability

 

Shaffer 1992

- 50% pain or stiffness at mean 7 years

- never more than mild with little functional disability

 

History

 

Insidious onset /  No history of trauma

 

Pain

 

Initially 

- at site of deltoid insertion

- at extremes of motion

 

Becomes more

- diffuse / severe / constant

- interferes with sleep

 

Then begins to decrease

- rest pain disappears

- pain only on movement

 

Stiffness

 

Develops after onset of pain

Difficulty reaching

- overhead

- behind back

 

Examination

 

Muscle atrophy

 

No point tenderness

 

Markedly decreased ROM

- abduction

- ER classically

- limited GH movement, increased ST movement

 

Frozen Shoulder Reduced ER

 

DDx Causes of reduced ER

1. Frozen shoulder

2. OA

3. Unreduced posterior dislocation

 

Pain on forced movement

- most sensitive indicator is pain on forced ER

 

Xray

 

Normal

 

Arthrogram / MRA

 

1. Reduced volume

- <10 ml of contrast can be injected

- normal = 20-30 ml

2. Obliterated axillary capsular recess

3. Thickened capsule

 

Management

 

Goals

- Relieve pain

- Restore range

- Remove secondary cause

 

Non Operative

 

Reassurance as first treatment

 

Careful explanation of 

- nature of disease

- NHx

- reassurance

 

Algorithm

 

Freezing Phase

- directed towards pain relief

- simple Analgesics / NSAID

- sling / ice / TENS

- intra-articular HCLA

- avoid physio as makes it more painful / doesn't increase ROM

 

Frozen Phase

- encourage hand use to avoid RSD

 

Thawing Phase

- gentle ROM & strengthening 

- consider intervention if prolonged / major functional disability

 

HCLA

 

Lorbach et al J Should Elbow Surg 2010

- compared oral corticosteroids to 3 doses of intra-articular corticosteroids

- best ROM and pain relief in intra-articular group although both effective

 

Operative Options

 

1.  MUA

 

Timing

- at least after 6/12

- in late frozen or early thawing  phases

 

Contra-indications 

- osteopenia

- previous fracture or surgery

- history instability

 

Complications

- fractures & dislocations

- cuff tears

- increased inflammation & scarring

 

Technique (Neviaser)

- GA or interscalene block

- confirm diagnosis with MUA (i.e. limited ROM)

 

1.  Abduction first

- gentle, 2 fingers

- sensation of tearing is the axillary fold tearing

 

2.  Rotation second

- must avoid fracture

- IR / ER in abduction

 

3.  HCLA +/- hydrodistension

 

Post-op physio

 

Results

 

Weber Clin Rheum 1995

- average 6 months post diagnosis

- 73% full recovery

- needed 6 weeks off work

 

2.  Hydrostatic Distension

 

Technique

- needle into GHJ under LA

- joint forcefully distended by injection

- 5 ml LA

- 1 ml steroid

- up to 40 ml Saline

- distension till capsular ruptures 

- sudden drop in resistance

- immediate post-op physio

 

Results

 

Rydell Clin Orthop 1992

- 22 patients

- 15 months

- MUA + hydrodistention + steroids

- 91% no or slight pain at 6 weeks

- 83% normal or almost normal ROM

 

Jacobs J Should Elbow Surg 2009

- 53 patients randomised to either MUA or steroid hydrodistention

- 2 year follow up

- no difference in two group

 

Quraishi et al JBJS Br 2007

- randomised trial of MUA v hydrodistention

- improved ROM in both groups

- more patients satisfaction and better shoulder scores in hydrodistention

 

3.  Open Release

 

Ozaki et al 1989 JBJS Am 1989

- one of first papers

- open release CH ligament and RC interval

- mean of 10 months post diagnosis

- MUA as part of procedure

- 94% relief of pain and complete ROM

 

Segmuller et al J Should Elbow Surg 1995

- released inferior and middle GH ligaments

- 24 patients

- 88% satisfied

- 76% normal function

 

4.  Arthroscopic release

 

Diagnosis

- +++ synovitis

- very tight shoulder to arthroscope

- capsule very thick

- very limited ROM

 

Arthroscopy Frozen Shoulder Synovitis

 

Technique

 

1.  Release rotator interval

- remove all tissue in between biceps and SSC

 

Frozen Shoulder Interval Release 1Frozen Shoulder Interval Release 2

 

2.  Release anterior IGHL

- from 3 o'clock down to 5 o'oclock

- leave labrum intact / anterior to labrum

- release inferior capsule with scissors / 6 o'clock

 

Frozen Shoulder MGHL ReleaseFrozen Shoulder IGHL ReleaseFrozen Shoulder Release IGHL Complete

 

Frozen Shoulder Inferior Release with scissors

 

3.  Mobilise SSC

- release adhesions on posterior and superior aspect

- some advocate release of intra-articular tendinous portion

 

4.  Release posterior IGHL

- place camera in anterior portal

- posterior to posterior labrum

- complete inferior release

 

Frozen Shoulder Posterior Capsule ReleaseFrozen Shoulder Posterior Release CompleteFrozen Shoulder Complete Inferior Release

 

5.  MUA with abduction

- remove instruments and camera

- tears inferior aspect of capsule

 

6.  Injection of HCLA

 

Results

 

Ogilvie-Harris et al Clin Orthop 1995

- MUA v arthroscopic release in 40 patients

- better outcomes in arthroscopic release at 2 and 5 years

- excellent in 15/20 arthroscopic

- excellent in 7/18 MUA

 

 

 

Glenoid & Scapula Fractures

Glenoid Fractures

 

Indications for Surgery

 

ORIF

- > 5mm step

- > 1/4 glenoid rim and displaced

 

Ideberg Classification Intra Articular Fracture

 

Type I

 

Fractures of the Glenoid rim

I A anterior 

I B posterior

 

Differentiate from small bony Bankart

- ORIF if > 1/4th or > 10 mm displaced (Neer)

 

Case 1

 

Glenoid Rim Fracture 1Glenoid Rim Fracture 2Glenoid Rim Fracture 2Glenoid Rim ORIF

 

Case 2

 

Glenoid FractureGlenoid Fracture CTGlenoid Fracture CT 2Glenoid ORIF

 

Case 3

 

Scapular fracture intraarticular glenoid axialScapula ORIF APScapula ORIF Lateral

 

Case 4

 

Glenoid Frac APGlenoid Frac AxialGlenoid Fracture CT

 

Type II

 

Transverse fracture through glenoid fossa

- inferior triangular fragment 

- exits lateral border scapula

 

Glenoid FractureGlenoid ORIF

 

Scapula Fracture XrayScapula Fracture Intra articular CT SagittalScapula Fracture Intra articular Glenoid Coronal CT

 

Glenoid Fracture 1Glenoid Fracture 2Glenoid Fracture 3

 

Type III

 

Oblique fracture through the glenoid    

- exiting through superior border of the scapula

- associated with AC fracture or ACJ dislocation

- includes the Coracoid

 

Type IV

 

Similar to II, larger superior fragment

- horizontal

- exiting thru the medial border of the blade

 

Glenoid FractureGlenoid Fracture 2Glenoid Fracture 3

 

Glenoid ORIFGlenoid ORIF 2Glenoid ORIF 3

 

Type V

 

Combination

- Va =IV+II

- Vb=IV+III

- Vc=IV+III+II

 

Type VI

 

Extensive comminution

 

Glenoid Malunion

 

Case 1

- untreated glenoid rim fracture

- patient with chronic instability

- treated with glenoid osteotomy

 

Glenoid Fracture Malunion CTGlenoid Osteotomy APGlenoid Osteotomy Lateral

 

Scapular Fractures

 

A.  Body

 

Often don't need ORIF
- well splinted by fascia / haematoma

- can treat non operatively

 

Scapula Body FractureScapular Body Fracture CT

 

Scapular Blade Fracture CTScapular Blade Fracture CT 2

 

Indications for surgery

- > 45 degrees of angulation of body

 

Scapular Body /> 45 degrees

 

B.  Neck

 

Indications for surgery

- > 450 angulation

- > 10 mm displaced (i.e. medial displacement

 

Case 1

- > 1 cm medial displacement

- ORIF via posterior / modified Judet approach

 

Scapula Neck FractureGlenoid Neck Fracture

 

Scapula ORIFScapula ORIF 3

 

Case 2

 

Glenoid DisplacementGlenoid Displacement CT

 

Glenoid ORIF 1Glenoid ORIF 2

 

C.  Spine

 

Scapula Blade Fracture CTScapula Spine Fracture

 

 

D.  Acromion

 

Spine scapula fracture

 

E.  Coracoid

 

Coracoid Fracture 1Coracoid Fracture 2

 

Coracoid Fracture CT 1Coracoid Fracture CT 2Coracoid Fracture CT 3Coracoid Fracture CT 4

 

Combined Glenoid and Scapula Fractures

 

Case 1

- displaced glenoid fracture and neck fracture

- ORIF both through posterior / Judet approach

 

Glenoid Scapular FractureComplex Scapular Fracture CT 1Complex Scapular Fracture CT2Complex Scapular ORIF

 

 

Humeral Shaft Fracture

 

Non operative Mangement

 

Indications

 

< 20o sagittal

< 30o coronal

< 3 cm of shortening

 

Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral

 

Options

 

1.  Vietnam Cast / hanging cast

2.  Functional bracing 3/52

 

Functional Humerus Brace

 

Results

 

United Humeral Fracture LateralUnited Humeral Fracture

 

Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative group nonunion 20% and 12% malunion

- operative group nonunion 8% v 1%

- no increased time to union or radial nerve palsy in operative group

 

Operative Managment

 

Indications

 

Absolute

- compound fracture

- radial nerve palsy post reduction

- failure to obtain / maintain acceptable reduction

- displaced Holstein Lewis with radial nerve palsy

 

Relative

- multi-trauma

- floating elbow

- obese (very difficult to splint)

- pathological fracture - won't heal

- segmental fracture

- bilateral humeral fractures

- brachial plexus injury - allows early rehab

 

Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral

 

Options

- antegrade IM Nail

- retrograde IM Nail

- ORIF with plate

 

Indications Plate vs Nail

 

Chapman et al J Orthop Trauma

- RCT antegrade nail v plate 84 patients

- union rates similar in each - 90%

- shoulder discomfort and decreased ROM with nail

- decreased elbow ROM with plate especially distal third

 

1.  Antegrade Humeral Nail

 

Humeral Nail APHumeral Nail Lateral

 

Relative indications

- segmental fracture - need very long plate

- impending pathological fracture

 

Technique

 

Set up

- lazy beach chair

- need to get II of shoulder and distal forearm

- patient relatively supine to ensure ease of AP distal locking

 

Anterolateral approach shoulder

- longitudinal split SS

- entry point at medial aspect GT

- entry with K wire or awl

- check down IM canal of humerus with II

- most nails have mild valgus proximal angulation

- increase diameter proximally with hand reamers

 

Pass guide wire

- can do closed

- can perform mini open to blunt dissect and protect radial nerve

 

Minimal reaming

 

Pass nail

- bury enough to protect cuff

- need to consider hardware removal

 

Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon

 

Distal AP locking screw

 

Careful repair of rotator cuff

 

Results

 

Cox et al J Orthop Trauma 2000

- 37 patients treated with antegrade nail

- 4 non unions and 4 delayed unions (>4 months)

- 6 patients had poor shoulder function (4 due to stiffness, 2 due to pain)

 

Complications

 

Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

- still incidence of shoulder pain

 

Humerus Prominent IM Nail

 

2.  Retrograde IM Nail

 

Relative indication

- distal 1/3 humeral fracture

- avoids shoulder pain

 

Technique

 

Set up

- Patient prone

- arm on table, need to flex elbow

 

Entry dorsal

- 3cm above Olecranon fossae

- gentle reaming to prevent blow-out

 

Distal locking with butterfly construct and screws

 

Proximal locking

- some have extendable hook

 

Complications

 

Distal blow out

- difficult problem

 

Nail removal

- not easy procedure

 

Results

 

Cheng et al J Trauma 2008

- RCT of antegrade v retrograde IMN

- similar union rates (>90%)

- longer time to perform retrograde IMN

- longer time to recover shoulder function in antegrade group

 

3.  Plate Osteosynthesis

 

Humeral Plate LateralHumeral Plate Long AP

 

Indications

- nerve injury requiring exploratation

 

Approaches

1.  Proximal 2/3

- anterior or anterolateral

2.  Distal 1/3

- posterior

 

Technique

 

A.  Anterior Approach Humerus

 

Sterile tourniquet

 

Incision lateral aspect of biceps

- incise deep fascia

 

Proximally

- retract deltoid laterally and biceps medially

 

Identify plane between biceps and brachialis

- protect MCN between the two

- identify and split brachialis in midline

 

Internervous plane

- radial nerve lateral brachialis

- MCN medial brachialis

 

Distal extension

- between brachialis and BR in distal 1/4

- find and protect radial nerve

 

4.5 mm DCP

- minimum 6 cortices above and below

 

B.  Anterolateral approach

 

Allows more distal plating

 

Utilise interval between triceps and brachialis

- identify and protect radial nerve distally between brachialis and BR

- extend proximally into deltopectoral groove

 

C.  Posterior Approach

 

Humerus ORIF Posterior Approach

 

Position

- lateral approach

- arm over bolster

 

Sterile tourniquet if needed

 

Midline incision

- interval between long and lateral heads

- Split medial head of triceps

- identify radial nerve proximally 

 

Radial Nerve Injury

 

Incidence

 

4% incidence of radial nerve injury

 

Associated with Holstein Lewis fracture

 

Holstein - Lewis JBJS Am  1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

 

Holstein Lewis

 

Incidence of laceration / entrapment

 

Noaman et al Microsurgery 2008

- operative exploration of 36 patients with radial nerve palsy

- entrapped in fracture site in 9 and lacerated in 8

- 9 epineural repairs and 5 nerve grafts

- neurolyis in remainder

 

Recovery

 

Average time to see recovery is 7 weeks

Average time to full recovery 15 weeks

Longest time to see recovery 7 months to 1 year

 

NHx

 

Sarmiento JBJS Am 2000

- 922 fractures managed in brace, 620 followed, no MUA

- radial nerve palsy in 11% / 101

- 1 radial nerve didn't recover

 

Pollock & Drake et al JBJS Am 1963

- 24 humeral shaft fractures with radial palsy (14/24 distal third)

- 9 of these were complete motor and sensory (8/9 distal third)

- treatment immobilisation or traction

- all had complete recovery

 

Options

 

1.  Explore + ORIF

- easy to make this decision if fracture requires operative management

 

2.  Manage non operative

- if no recovery tendon transfer

Instability

Anterior

Acute Anterior Dislocation

EpidemiologyAnterior Shoulder Dislocation

 

Most common form of shoulder instability

- young males 

- M:F = 2:1

 

Aetiology

 

Indirect ER and abduction moment on arm

- disruption of anterior stabilisers

 

History

 

Initial injury

- severe pain in shoulder

- ± transient paraesthesia / dead arm syndrome

 

History of dislocations

 

Examination

 

Very painful & tender shoulder

- significant muscle spasm

- arm held across abdomen

 

Hollow under acromion

- fullness in anterior shoulder

 

Axillary nerve palsy

- important to exclude

- look for parasthesis in badge area

- 20 years = 5% --> 90% recover

- 80 years = 90% --> 10% recover

 

Left Deltoid Wasting

 

Musculocutaneous Injury + Rotator Cuff Tear

 

Musculocutaneous nerve injuryMusculocutaneous Nerve Injury 2Supraspinatous Infraspinatous Wasting

 

Diagnostic Dilemma

 

Patient with history traumatic dislocation / wasting of shoulder / loss ROM

1.  Wasting deltoid (AXN)

2.  Wasting SS, not IS (RC tear)

3.  Wasting SS & IS (SSN injury or massive tear)

4.  Wasted deltoid + SS/IS (upper trunk brachial plexus or AXN palsy with RC tear)

 

Axillary nerve palsy with Massive Rotator Cuff Tear

 

Xray

 

True AP

- dislocation

- fracture GT

- bony bankart

 

Shoulder Dislocation Greater Tuberosity FractureAnterior Shoulder Dislocation AP

 

AP in IR

- Hill Sachs lesion

 

Scapular Lateral

- dislocation

- humeral head should be in centre of Y

 

Anterior Shoulder Dislocation0002Shoulder Anterior Dislocation Scapula Lateral

 

Axillary Lateral

- dislocation

- Hill Sachs

 

Shoulder Fracture DislocationAnterior Shoulder Dislocation Axillary LateralShoulder Hill Sachs Axillary Lateral

 

Garth

- aim beam caudally

- bony bankart

 

Bony Bankart Xray

 

Classification

 

According to direction seen on xrays

1. Subcoracoid / most common

2. Subglenoid

3. Intrathoracic

 

Management

 

Reduction

 

ASAP

- appropriate analgesia & muscle relaxation / conscious sedation

- atraumatic closed reduction performed

- if unsuccessful, may require GA

- rarely need open reduction

 

Post-reduction xray

- confirm reduction

- rule out associated fracture

 

Shoulder Post Dislocation Check Reduction

 

Techniques

 

1.  Stimpson

- patient prone

- arm hanging over side of bed

- weight applied to wrist

- give mild sedation

- not appropriate if obese / sleep apnea etc

 

Stimpson Method

 

2.  Harvard / Traction & Countertraction method

- patient supine

- traction with abduction

- countertraction via sheet around axilla

- similar to Hippocratic but no foot in the axilla

 

3.  Kocher

- externally rotate and maximally abduct arm

- relocate via adduction

- nil IR til located to avoid humeral fracture

 

4.  Hippocrates

- foot in arm pit

- apply longitudinal traction 

 

Immobilisation

 

No effect on re-dislocation rate

- no sport for 6/52 reduces dislocation rate

 

Protocol

- sling for comfort

- avoid provocation 6/52

- no sport until painless FROM

 

ER brace

 

Theoretical

- tightens SSC
- reduces bankart lesion into anatomical location whilst healing

- may reduce redislocation rates

- problems with compliance as is uncomfortable and in young population

 

Itoi et al JBJS Am 2007

- RCT ER brace v sling 198 patients 3 weeks duration

- relative risk reduction 38%

- 26% recurrence v 42% (p < 0.03)

- particularly beneficial if < 30

 

Finestone et al JBJS Br 2009

- RCT 51 patients

- no difference

 

Rehabilitation

 

Start with ROM exercises

- pendulum / active Assisted / active

 

Progress to shoulder strengthening

 

Prognosis

 

1. Age at first dislocation

 

Increased in young

- the majority of recurrences occur within 2 years of the first traumatic dislocation

 

Classic paper Rowe CORR '61

- < 20    90% redislocation

- 20-30  60% redislocation

- 30-40   30% redislocation

- > 40     10% redislocation

 

McLaughlin and MacLellan 1967 

- 95% traumatic dislocations in teenagers recurred

 

Simonet and Cofield 1982 

- overall incidence of recurrence 33% over 4 years

- 66% in patients < 20 years

- 17% in patients 20 - 40 years

 

2. Trauma of First Dislocation

 

Decreased incidence of re-dislocation with 

- severe trauma

- associated fracture (usually LT / GT)

 

3. Activity

 

Re-dislocation more common in athletes

- 80% in athletes

- 30% in non-athletes

 

4. Rehabilitation

 

Activity restriction & effective muscle strengthening reduces re-dislocation

- overall re-dislocation rate 25% at 3 years in Army

- need strict adherence with program

 

Indications Operative Management in Acute Dislocation

 

1.  Rotator cuff tear

2.  Displaced GT fracture

3.  Large glenoid rim fracture

4.  ? Athlete

 

Rotator cuff tear

 

Diagnosis

 

Important not to miss

- high incidence in patients > 40

- suspect if pain or decreased ROM

- MRI

 

Incidence

 

Berbig et al J Should Elbow Surg 1999

- prospect ultrasound on 167 patients with dislocation

- full thickness tears in 31.7%

- only acute tears in patients younger than 60

- control group had no FT tears in patients younger than 60

 

Management Options

 

A.  Repair RC / leave Bankart

B.  Repair RC and Bankart

 

Voos et al Am J Sports Med 2007

- retrospective review of arthroscopic repair of RC and labrum

- average age 47, 16 patients

- good or excellent results in > 90%

 

2.  Displaced GT Fracture

 

Indications

- > 5 mm displacement

 

Management

- ORIF

- screw + suture repair

- screw alone in young patient

 

Shoulder Dislocation Non Displaced GT FractureGT ORIF

 

3.  Large Glenoid Rim Fracture

 

Indications

- > 25 - 30% and displaced

 

Management

- open or arthroscopic

- fix with 1 or 2 cannulated screws

 

Glenoid Rim FractureGlenoid Rim Fracture CTGlenoid Rim ORIF

 

4.  Acute dislocation in professional athlete

 

Robinson et al JBJS Am 2008

- prospective randomised control trial arthroscopic surgery in first time dislocators

- 88 patients under 35, arthroscopic stabilisation v arthroscopic lavage

- reduced risk of recurrence by 80%

- patient satisfaction and shoulder scores significantly improved

 

Kirkley et al Arthroscopy 2005

- RCT of 40 patients for arthroscopic stabilisation v immobilisation

- 3 recurrences in surgical group, 9 in non surgical group

- small improvement in shoulder scores in operative group

 

Jakobsen et al Arthroscopy 2007

- RCT 76 patients

- arthroscopy to diagnose labral injury

- either open repair or non operative

- 74% unsatisfactory results at 8 years in non operative group

- 75% good results in operative group (1 redislocation)

Anterior Instability

Epidemiology

 

Traumatic initial cause in 95%

 

M:F 2:1

 

Age of initial dislocation inversely related to recurrence rate

- patients younger than 20 have a redislocation rate of 90%

- between 20 - 40 years, redislocation rate of 60%

- patients > 40 years have a 10% rate of dislocation but a higher rate of cuff tears (up to 40% in patients > 60yrs)

 

Anatomy & Stability

 

1. Passive Stabilisers

 

Glenoid labrum 

- significant deepening by 50%

- labrum attaches capsule / ligaments / biceps

 

Negative intra-articular joint pressure

 

Joint fluid adhesion/ cohesion

 

Capsule 

- attaches to SNOH

 

Coracoacromial arch

- prevents superior displacement

 

Coracohumeral ligament

- attaches base of coracoid

- to lesser and greater tuberosity 

- passess through rotator interval between SS and SSC

- static restraint to anteroinferior translation in the adducted shoulder

 

Capsulo-ligamentous structures

 

1.  IGHL

 

Most important

- resists anterior translation in abduction and ER

- anterior & posterior band with sling between

- anteror band limits ER at abduction > 90°

 

Origin

- anterior band glenoid 3 o'clock

- posterior band 9 o'clock

 

Insertion

- inferior anatomical neck / head

 

Arthroscopy Normal IGHL Humeral AttachmentIGHL

 

2.  MGHL

 

MGHL in Buford Complex

 

Action

- behind SSC

- 2° restraint anterior translation

- limits ER at 45° Abduction

- present in 60% population

 

Origin

- supraglenoid tubercle below SGHL

 

Insertion

- medial to LT

 

3.  SGHL

 

SGHL

 

Action

- adjacent to biceps tendon

- prevents inferior subluxation 

- functions only in adduction

- no function in decreasing anterior translation

- present 50% population

 

Origin

- supraglenoid Tubercle 

 

Insertion

- LT

 

2. Dynamic Stabilisers

 

Rotator Cuff

- SSC resists anterior translation

- compresses head into glenoid socket

 

LH Biceps

 

Deltoid 

- especially when arm is elevated 90o

 

Scapular Rotators 

- move glenoid into stable position

 

Pathology

 

No essential pathological lesion responsible for every recurrent subluxation or dislocation

 

Thomas and Matsen Aetiology Classification

 

AMBRII 

- Atraumatic, Multidirectional, Bilateral

- Rehabilitation, Inferior capsular shift, closure rotator Interval

 

TUBS 

- Traumatic, Unidirectional, Bankart, Surgery

 

1.  Labrum / Ligament / Capsule

 

A.  Bankart lesion

 

Pathology

- described in 1938 

- humeral head forced through capsule

- humeral head tears fibrocartilaginous labrum from almost entire anterior 1/2 of glenoid rim 

- is an IGHL avulsion

- usually between 3 and 6 o'clock

 

MRA

- see detachment of anterior labrum

 

Anterior Bankart Lesion MRIShoulder MRI Anterior Bankart

 

Arthroscopy

 

Anterior bankart lesion ArthroscopyArthroscopy Soft Tissue Bankart

 

Incidence

- present in 85% traumatic recurrent dislocations 

- may be associated with avulsion fracture of glenoid rim / bony bankart

 

B.  Excessive Capsular laxity 

 

Incidence

- may be present alone or with Bankart lesion

- 30% have both

- 85% previous failed surgical procedures

 

Causes

- congenital collagen deficiency / MDI

- plastic deformation of capsuloligamentous complex

- single macro-traumatic event or repetitive micro-traumatic events

 

C. Capsular Tears

 

Capsular Tear 1Capsular Tear 2Capsular Tear 3

 

Capsular Repair 1Capsular Repair 2

 

D.  HAGL

 

Definition

- avulsion of IGHL from anterior humeral neck

- Humeral Avulsion of Glenohumeral Ligament

 

Incidence

- 2 - 10%

 

Associations

- can be in combination with anterior bankart (Floating IGHL)

- association with subscapularis tear

 

Xray

- may see bony avulsion

 

MRA

- enlarged inferior  pouch

- discontinuity of IGHL / J sign

 

MRI Normal Humeral IGHL InsertionMRI HAGL J Sign

 

Arthroscopy

- will see exposed subscapularis muscle

 

Arthroscopy HAGL Normal Humeral attachment IGLH

 

Management

 

A.  Open Repair

- take down SSC

- repair via bone anchors to inferior neck

- can cause limitation ER

 

B.  Arthroscopic repair

- 70o scope and 5 o'clock portal

 

E.  Bankart Variations

 

ALPSA

- anterior labrum periosteal sleeve avulsion

- labral-ligamentous structures shifted medially

- roll up under the periosteum

 

Perthes Lesion

- stripping of the scapular periosteum medially

- labrum may or may not be attached

 

Perthes Lesion MRI 1Perthes Lesion MRI 2Perthes Lesion MRI 3

 

GLAD

- glenoid labrum articular disruption

- damage to the glenoid cartilage

- labrum undisplaced

 

Shoulder GLAD

 

F.  Muscle

 

Cuff Tears

- Present as pain or weakness 

- > 40 years = 30%

- > 60 years > 80% 

 

Increased Rotator Interval

- between SS and SSC

- tends to open up with AMBRI

 

2.  Bony

 

A.  Bony Bankart

 

Xray

- AP

- Garth (aim beam caudally)

 

Bony bankart XrayShoulder Garth ViewBony Bankart

 

Importance

- large bony bankart increases risk of failure of soft tissue bankart repair

 

Diagnosis

- may need CT to decide the size best

 

Burkhart and De Beer Arthroscopy 2000

- described the inverted pear appearance

- loss of bone antero-inferior

 

Small

 

CT Sagittal Small Bony Bankart

 

Large

 

CT Axial Large Bony BankartCT Axial Large Bony BankartLarge Bony Bankart

 

Size calculation

 

Bony Bankart Size CalculationGlenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 1

 

Lo Parten and Burkhart, Arthroscopy 2004

- calculation of percentage bone loss arthroscopically

 

1.  Inferior glenoid is nearly a perfect circle

- centre is the bare area of the glenoid

- measure anterior radius v posterior radius at this level

 

2.  Calculate the diameter of the inferior circle

- twice the posterior radius

 

3.  Calculate the difference between anterior and posterior radius

 

The average diameter is 24 mm

- hence 12 mm posterior and 12 mm anterior

- if lose 8 mm anteriorly

- 12 mm posterior and 4 mm anterior

- calculation is 8/24 = 30%

 

Risks

 

25% loss and above poor prognostically

- means approximately 7.5 mm anterior bone loss

< 4mm anterior to bare area

- > 30%

- likely not amenable to soft tissue bankart repair alone

 

Acute Bankart Repair

 

Sugaya et al JBJS Am 2005

- demonstrated union of fragment with arthroscopic restoration

- must mobilise fragment, restore anatomically

- otherwise bony procedure

 

Decision Making

 

A.  Small fragment < 15%

- arthroscopic bankart repair

- can attempt to include fragment

 

B.  Intermediate 15 - 25%

 

C.  > 25%

- must restore glenoid rim

- acute restoration of bony frament or

- bony procedure / Latarjet / Bristow

 

B.  Hills Sachs Lesion 

 

Definition

- lesion posterior aspect of head

- where head engages on anterior glenoid

 

Xray

- AP with IR

- Garth view

 

Hill Sachs XrayLarge Hill Sachs Xray

 

CT

 

Hill Sachs CT

 

Arthroscopy

- cartilage each side of lesion

- this differentiates it from the normal bare area next to infraspinatous

 

Arthroscopy Hill Sachs LesionLarge Hill Sachs

 

Issue

- large lesion can contribute to dislocation

- head engages defect in external rotation & abduction

 

Large Hill Sachs MRICT Hill SachsHill Sachs

 

Dynamic CT

Dynamic CT 1Dynamic CT 2Dynamic CT 3

 

Measurement

 

Estimate percentage of articular surface

- concern if 25% or more

 

Hill SachsHill Sachs Measurement

 

Management options for engaging Hill Sachs

 

1.  Posterior capsular advancement / Remplissage

2.  Humeral head allograft

3.  Anterior Bony Procedure / Latarjet / Bristow

- Hill Sach's lesion unable to engage on anterior glenoid rim

4.  Humeral osteotomy

 

Remplissage

 

Theory

- described by Wolf Arthroscopy 2008

- advance IS into Hill Sachs lesion

- makes lesion extracapsular

 

Technique

- perform arthroscopic transtendinous advancement of IS and capsule into defect

- tie knots from subacromial space

 

Results

 

Zhu et al Am J Sports Med 2011

- 8.2% failure in 42 cases

 

Humeral head allograft

 

Humeral Head Allograft APHumeral Head Allograft Lateral.jpg

 

Technique

- anterior deltopectoral approach

- ER shoulder

- debride base of Hill Sachs

- secure allograft with 2 x screws

 

Issue

- late resorption of graft with recurrent instability

 

Humeral Head Allograft Resorption

 

Humeral Head Osteotomy

 

Weber et al JBJS Am 1984

- series of 180 patients

- very low risk of recurrence

 

C.  Abnormal Version 

 

Glenoid or Head

- rarely a cause

Arthroscopic Bony Bankart Repair

Case 1: Acute Presentation

 

Bony Bankart Xray

 

Bony Bankart Fixation 1Bony Bankart Fixation 2Bony Bankart Fixation 3

 

Bony Bankart Fixation 4Bony Bankart Fixation 5Bony Bankart Fixation 6

 

Bony Bankart Fixation 7

 

Arthroscopic Stabilisation

Labral Repair

Arthroscopic Shoulder Stabilisation

 

 

1.  EUA

 

Compare both shoulders

- ROM

- anterior and posterior draw

- load and shift

- sulcus sign

 

2.  Labral Assessment

 

A.  Above equator

 

Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability

 

Beware normal variations in this area

 

Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types

 

1.  Sublabral foramen

 

Arthroscopy Anterior Sublabral ForamenShoulder Sublabral foramen

 

2.  Sublabral foramen with cord like MGHL

 

Buford Complex

 

3.  Absence of AS labrum with cord like MGHL

- Buford complex

 

Buford Complex

 

B.  Below equator 

 

Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)

 

Anterior Bankart LesionShoulder Anterior Bankart

 

C.  Exclude HAGL

 

Assess anterior IGHL attachment to humeral neck

 

Normal IGHL Humeral Attachment

 

D.  Posterior Labrum

 

Always assess

- place camera through anterior portal

 

Arthroscopy Posterior Labral Tear

 

3.  Bony Assessment

 

A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?

 

Shoulder Anterior Glenoid DeficiencyGlenoid Bone Loss

 

Glenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 2

 

Solution

- anterior bony procedure

 

B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

- only a problem if engages with head centred and ER < 30 - 40o

 

Hill Sachs ArthroscopyHill Sachs Lesion SuperiorShoulder Engaging Hill Sachs

 

Solution

 

1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid

 

2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular

 

3.  Humeral head allograft

 

4.  Humeral head osteotomy

 

Technique Anterior Bankart Repair

 

Labral Repair

 

Set up

 

Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg

 

Portals

 

Shoulder Portals Labral Repair

 

A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work

 

B.  Anteroinferior Portal (AI)

- for anchor placement

- rotator interval just above SSC
- 1 cm lateral to glenoid

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal

 

Shoulder Scope Anteroinferior Portal

 

Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula

 

Shoulder Arthroscopy Anterosuperior PortalShoulder Stabilisation 2 Anterior PortalsRotator Interval 2 cannulas

 

Problem

- can make rotator interval very crowded

- repair can be done through single portal

 

Mobilise labrum

 

Shoulder Scope Bankart RaspShoulder Stabilisation Labral Mobilisation

 

Labral mobiliser / rasp / scissors

- labral tear can be obvious, but may have partially healed or healed medially

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view

 

Shoulder Arthoscopy Bankart MobilisationShoulder Scope Bankart Mobilisation

 

Bony Fragments

- important to recognise

 

Options

 

1.  Incorporate in repair

- pass sutures medially to bony fragments

 

2.  Remove / debride

 

Shoulder Arthroscopy Bony Bankart

 

Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs

 

Shoulder Stabilisation Anterior Labral MobilisationShoulder Stabilisation Anterior Labral Mobilisation 2

 

Labral Repair

 

Anchors

- 2.3 or 3.2 mm bioabsorbably anchors

 

Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point

 

Arthroscopy Bankart Anchor Drill GuideInferior Glenoid Anchor

 

Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

- suture passer with loop / single nylon in anterior to posterior direction

- retrieve through portal

- retrieve suture posterior to anterior through portal

 

Shoulder Bankart Repair Suture PasserShoulder Instability inferior Suture passage

 

Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect

 

Arthroscopy Anterior Bankart Repair

 

Remaining anchors

- 5 mm apart

- beware lysis and risk of anterior glenoid / postage stamp fracture

- up to glenoid equator

- usually three in total

 

Shoulder Bankart RepairShoulder Scope Bankart Repair 2

 

Additional Issues / Continued Instability

 

Capsular Shift

- take bite of capsule with suture passer, then labrum

 

Shoulder Instability Capsular Plication

 

SLAP

- contributes to inferior instability

- requires repair

 

Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30o ER

- do away from glenoid on humeral side or will make patient very stiff

- SGHL to MGHL

- must do last

 

Results

 

Primary Arthroscopic Stabilisation

 

Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

- identified patients < 25 / ligamentous laxity / Hill Sachs > 250mm3 high risk

 

Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability

 

Arthroscopic v Open Bankart Repair

 

Bottoni et al Am J Sports Med 2006

- RCT open v arthroscopic, 2 - 3 year follow up

- 2 failures in open group v 1 failure in arthroscopic group

- open took significantly longer and was associated with decreased ER

 

Revision of Failed Arthroscopic Stabilisation

 

Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

- redislocation in 3 shoulders all with engaging Hill Sachs and ligamentous laxity

 

Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence

Glenoid Allograft / Autograft

Tibial Allograft

 

Distal Tibial Allograft to Glenoid

 

Humeral Head Autograft

 

After humeral head resurfacing

 

Chronic Anterior DislocationHumeral Head Autograft to Glenoid

 

Humeral Head Autograft to GlenoidHumeral Head Autograft

 

HAGL

DefinitionHAGL Arthroscopy

 

Humeral Avulsion of Glenohumeral Ligament

 

Incidence

 

Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%

 

Bhatia KSSTA 2012

- 10% incidence of HAGL

 

Bigliani et al J Ortho Research 1992

- cadaveric dislocations

- 25% HAGL

 

Why the difference with cadavers

- ? differences in tissue

- HAGL lesions heal / don't always cause instability

 

Type

 

Bony avulsions (BHAGL)

 

Soft tissue

- humeral

- humeral and bankart (floating)

- posterior / Reverse HAGL

 

Pathology

 

Pouliart J Should Elbow Surg 2006

- cadaveric study

- extensive capsular injury +/- SSC required for HAGL to cause instability

 

MRA

 

Normal

 

Shoulder MRI Normal Humeral IGHL InsertionMRI Normal IGHL

 

Abnormal

- J sign

 

HAGL MRI

 

Arthroscopy

 

Normal

 

Normal Humeral Attachment IGHL

 

Abnormal

 

HAGL

 

Management

 

1.  HAGL

 

Open Technique

 

Detach lower half SSC

- L Shaped tenotomy

- repair IGHL to surgical NOH

 

Arthroscopic Technique

 

Burkhart

- 70o scope

- 5 o'clock portal through SSC with arm adducted

- danger to MCN if arm abducted at all with insertion 5 o'clock portal

- ensure good angle to proximal humerus with needle, for insertion of anchors

- may use suture passers from posterior portal

 

HAGL 1HAGL 2HAGL 3

 

2.  Bankart + HAGL (Floating)

 

Options

- arthroscopic repair both

- open repair both

- arthroscopic repair bankart, open HAGL

- arthroscopic repair bankart, leave HAGL

 

Kim et al Arthroscopy Supplement 2006

- all arthroscopic, 8 good results

 

Rhee et al J Should Elbow Surg 2007

- 4 floating HAGL, open treatment

- loss 15o ER
- elected to leave humeral side in volleyballer for risk of loss of ER

 

Bhatia KSSTA 2012

- subscap sparing approach in 7 patients

- good outcome

 

Latarjet / Bristow

Bristow

 

Concept

 

Non-anatomical bony block 

- transfer of coracoid process through subscapularis

- dynamic anteroinferior musculotendinous sling

- provides subscapularis tenodesis

- preventing lower portion from displacing proximally as arm abducted

- when shoulder in vulnerable position abduction and ER

 

BristowBristow CT

 

Indications

 

1.  Contact Sportsman

- sportsman who will return to dislocating action and loss of ER not a problem

- football, basketball

 

2.  Large bony bankart

- > 25 - 30%

 

Large Bony Bankart CT0001Large Bony Bankart CT0002

 

Glenoid bony defect

 

 

Large Bony BankartInverted Pear Glenoid

 

3. Large Hill Sachs

- prevent engagement

 

Large Hill SachsEngaging Hill Sachs

 

4.  Poor soft tissue

- multiple dislocations

- anterior labrum very poor quality

 

5.  Revision surgery

- i.e. failed arthroscopic or open soft tissue bankart

 

Problems

 

1.  Loss of ER 12-20°

- problem if throwing athlete

- subscapularis is relatively shortened 

 

2.  Screw problems 2-14%

 

3.  Instability 1-20%

- does not address bankart pathology

- difficult to revise with scarring in abnormal positions 

 

4.  Injury MCN

 

Technique

 

Hovelius

- correct positioning of transferred coracoid process critical to success 

- must be near but not over anterior glenoid rim

 

Good results can be correlated with

 

1. Coracoid process < 5 mm medial to glenoid rim

2. Coracoid positioned inferior to transverse equator of glenoid

3. Bony union develops between coracoid & scapula

4. Fixation screw purchases posterior glenoid cortex

5. Screw does not penetrate articular surface

 

Latarjet

 

Difference from Bristow

 

Transfers larger fragment

- allows 2 x screw fixation of coracoid to neck of scapula

 

Latarjet APLatarjet Lateral

 

Indications

- large > 20-25% bony Bankart

- revision surgery

- contact athlete

 

CT Large Bony Bankart

 

Contra-indication

- ? throwing athlete

- can lose considerable ER

 

Technique

 

Approach

 

Deltopectoral approach

- divide clavipectoral fascia at lateral edge of conjoint

 

Coracoid

 

Identify coracoid

- use fang retractor on superior surface to identify entire coracoid

- strip Coracoacromial ligament off lateral coracoid

- take pectoralis minor off medially

 

Divide coracoid

- 3 cm long

- use 90o oscillating blade on microsagittal saw 100

- medial to lateral

 

Prepare coracoid

- release conjoint for length, identify and protect MCN

- pect minor surface will be placed onto glenoid

- remove cortex with burr

- opposite side clear soft tissue with diathermy

- hold coracoid with Kocher forceps

- make 2 indentations with small burr where 2 x drill holes will be

- stops drill spinning off, ensures drill holes are sufficiently far apart

- 2 x 2.5 mm drill holes, tap, countersink

 

Deep Approach

 

SSC

- identify 3 sisters inferiorly

 

A.  Divide muscle transversely at inferior 1/3 of SSC

- at muscle is easier to take off capsule

- also want to be inferior

- do so by inserting scissors and opening blades vertical

- use sponge to separate from capsule

- insert fang superiorly / blunt homan medially for view

 

B.  Take down superior half of SSC

- repair later

 

Capsule

- feel joint line

- 2 x stay sutures 2 ethibond superiorly and inferiorly

- these must be medially over glenoid

- then divide capsule vertically with knife medial to stay sutures

- want maximum amount of capsule length to repair to anterior glenoid

- this prevents IR contracture

 

Dissect capsule from SSC

- inferiorly

- medially

- will have a free medial edge to repair to anterior edge glenoid

- may be easier to do this after osteotomy coracoid

- use scissors to dissect capsule superiorly

- beware inferiorly as AXN here

 

Exposure

- remove retractorr

- insert fukuda to expose humeral head, joint, glenoid

- again use fang / blunt homan superiorly and medially for exposure

 

ORIF Bone Block

 

Bone block

- clear glenoid 3 - 6 o'clock

- need medial area to place bone

- can use burr

- place bone on glenoid using Kockers to hold

- 2 x drill bits, leave first one insitu

- bone must not overhang medially

- bicortical, tap, typically 30 - 40 mm partially threaded cancellous

 

Latarjet Scapular LateralLatarjet Axillary LateralLatarjet AP

 

Capsule repair

 

Remove Fucuda

- find capsue with stay sutures

- insert 2 x 3 mm absorbable anchors 3 and 5 o'clock

- pass in mattress formation through capsule

- can use Depuy Mitek Suture grasper

- pass this through capsule lateral to medial, grasp suture

- tie capsule down, ensure knot goes down past bone block to glenoid

 

Results

 

Burkhart et al Arthroscopy 2007

- 102 procedures for patients with the inverted pear glenoid +/- engaging Hill Sachs

- 4.7% recurrence rate

- 5o loss or ER

 

Boileau et al Arthroscopy 2010

- arthroscopic Latarjet

- 6/47 had to be converted to open

- no recurrence of instability at 16 months

- 1 bony block fracture and  7 migrations

- potentially dangerous and difficult procedure

 

Complications

 

Failure of fixation

 

Non union of coracoid

- need to carefully prepare both surfaces

- good compression

 

Suprascapular nerve injury

- screws too long, or too superior

 

OA

- bone block too medial

 

Dislocation

- too high, can dislocate under bone block

- too low, can dislocate over bone block

 

Failed Latarjet APFailed Latarjet Lateral

 

Open Bankart Repair

Aim

 

Repair of the anterior capsule & avulsed labrum to anterior glenoid 

- anatomic repair

 

Usually combined with a capsular shift

 

Contraindications

 

Bony bankart > 25% glenoid

 

Technique

 

Position

- beach chair position

- arm free

- Mayfield head ring / Spyder and Tmax

 

Incision

 

Can perform axillary incision

- in axillary fold

- mobilise skin to gain view

- more cosmetic scar

- more difficult visualisation

 

Axilary Incision 1Axillary Incision 2

 

Superficial dissection

- deltopectoral approach

- cephalic vein lateral with deltoid

- divide clavipectoral fascia

- mobilise lateral aspect conjoint tendon

- insert shoulder retractor deep to conjoint

- expose subscapularis with three sisters inferiorly

 

Increase exposure

- +/- partially detach conjoint tendon from coracoid

- ± partially release P major tendon (1.5 cm) from humerus

- can take of tip of coracoid (predrill for lateral repair)

 

Deep Dissection Options

 

Note:

Always leave inferior 1/4 of SSC

- protects AXN

 

L shaped incision in SSC / Capsulotomy 

Technique

 

Mark lower 3/4 of SSC

- ER shoulder

- use knife to divide muscle belly transversely

- expose capsule underneach

- use Cobb / dissecting scissors

- pass artery forcep up between capsule and SSC to rotator interval

- open interval further by spreading forceps

- tagging sutures in SSC medially (artery clips)

- divide SSC tendon vertically down onto forcep protecting capsule

- carefully elevate SSC from capsule medially using Cobb

 

Separate vertical incision in capsule

- right on humeral insertion

- superior and inferior

- stay on articular margin at all times

- can release down past 6 o'clock if wish to perform capsular shift

- usually don't perform horizontal / T shaped capsulotomy if repairing labrum

- T shaped capsulotomy used for MDI

 

Repair

- insert Fukuda retractor to expose joint

- displaces head posteriorly, exposes labrum

- inspect for pathology: labral detachment / loose bodies / loose capsule

- labrum mobilised

- bony glenoid roughened to bleeding surface

- suture anchors at 3, 4 & 5.30 

- sutures passed through labrum and capsule

 

Capsular plication / shift as required

- always repair with arm ER 30o to prevent loss of ER

- check ER with arm adducted and abducted

- need 50% of normal ER / other side

 

Tie medial labral / capsular sutures

- recheck ER as above

 

Subscapularis repaired / close rotator interval if shoulder still loose

 

Post-op

- shoulder immobiliser for 6/52 with pendulars

- no ER

- elbow & hand exercises

- ROM exercises at 6/52 (passive, active assist, active)

- muscle strengthening at 3/12

- return to sport at 6/12

 

Results

 

Rowe et al JBJS Am 1978

- classic quoted paper

- 5 recurrences in 145 patient(3.5%)

 

Flatow et al Orthopedics 2006

- 41 open stabilisations followed for average 6 years

- one recurrence

- average loss of ER 4o

 

 

 

 

Other Surgical Techniques

Putti-Platt

 

Concept

 

Plication subscapularis & capsule

 

Problems

 

Loss ER 

Secondary OA if ER < 0°

 

Contraindication

 

MDI

- will force head out posteriorly

 

Technique

 

Divide SSC 2.5cm from insertion 

- may divide capsule in same plane

- re-attach lateral flap to convenient medial soft tissue eg under surface of capsule

- double breast medial muscle over lateral stump

- limit ER to neutral

 

Results

 

Kiss et al J Should Elbow Surg 1998

- 70 Putti platts assessed clinically and with xray at average 9 years

- 11% redislocation rate

- 29% moderate and with 1 severe OA

- 11% pain at rest

- average loss of ER 23o

- 83% fully satisfied

 

Magnusson-Stack

 

Concept

 

Lateral advancement of SSC and capsule

- transfer of subscapularis from LT 

- across bicipital groove to GT

- Magnusson recommended distal transfer as well to allow subscapular sling

 

Bone Block Procedure

 

Concept

 

Transfer of bone graft to anterior glenoid rim

- Eden-Hybinette & Oudart procedures

 

Problem

 

Worse results than Putti-Platt with high incidence OA >10%

 

Osteotomy Humeral Head / Glenoid

 

No evidence to support either in most circumstances

- Glenoid neck osteotomy high rate of serious complications

 

Indication

- malunion post fracture

 

Glenoid MalunionGlenoid Osteotomy

 

 

 

 

Remplissage

 

Indications

 

Engaging Hill Sachs

 

Engaging Hill SachsEngaging Hill Sachs

 

Engaging Hill Sachs 1Engaging Hill Sachs 2

 

Technique

 

Tips

1.  Insert Hill Sachs anchors before performing bankart repair

- may be easier to do with humeral head subluxed over glenoid

- increases room to more

2.  May be best to clear subacromial space before inserting Hill Sachs anchors

 

Posterior portal glenohumeral jont

- camera anterior portal

- debride Hill Sachs

 

Hill Sachs DebridementRemplissage Anchors 1Remplissage Anchor 2

 

Insert 2 x anchors

- insert both via posterior portal

- leave one set of sutures out through portal

- separate stab incision posteriorly to retrieve other set of sutures into subacromial space

- use bird beaks or suture runner

 

Remplissage Anchors

 

Subacromial tying

- tip:  may be best to do this before passing anchors into Hill Sachs defect

- redirect posterior portal into subacromial space

- camera via lateral subacromial portal

- debride posterior subacromial space carefully to find sutures

- may want to place suture savers over sutures

 

Subacromial sutures

 

Knots

- separate with birds beak

- tie these knots (white) directly

 

Remplissage Subacromial Space

 

Knots / double pulley

- tie two limbs of separate anchors together

- use other limbs to oppose knots to tissue

- then tie other limbs

 

Remplissage Double PulleyRemplissage Subacromial Knots

 

Camera back into glenohumeral joint

- check capsule tied down into defect

 

Shoulder Post Remplissage

Revision Stabilisation

Causes for failure

 

1.  Patient factors

 

A.  Recurrent Trauma

- contact athletes higher risk

 

B.  MDI / Ligamentous Laxity / Voluntary dislocaters

 

C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow

 

2.  Surgeon Factors

 

A.  Unrecognised bony defect

- large bony bankart

- large engaging Hill Sachs

 

B.  Non Anatomical repair

 

C.  Poor sutures / poor knots / insufficient anchors

 

D. Unaddressed capsular laxity / Laxity RC interval / poor anterior labrum

 

E.  Posterior capsular tear / incorrect diagnosis / MDI

 

Management

 

Identify cause of recurrent instability

 

History

- traumatic or atraumatic

 

Examination

- MDI

 

CT

- large Hill Sachs

- large Bony Bankart

 

MRI

- assess anchor position

- reassess labral repair / integrity

 

Rehabilitation

 

Long period non operative

- best results if muscle control  and strength are optimal

 

Revision Options

 

1.  Revision arthroscopic stabilisation

 

Indications

- no bony defect

- poorly done original surgery

- traumatic redislocation

 

Technique

- repair labrum

- capsular plication

- +/- rotator interval closure

 

2.  Open stabilisation

 

Indications

- as above

 

3.  Laterjet

 

Indications

- bony defect

- large Hill Sachs

 

Results of revision surgery in those without bony defects

 

Arthroscopic revision post failed arthroscopic stabilisation

 

Franchesci et al Am J Sports Med 2008

- revision labral repair / capsular plication +/- rotator interval closure

- 1 failure

 

Arthroscopic revision post failed open stabilisation

 

Boileau et al Arthroscopy 2009

- 22 cases post Latarjet and open Bankart

- arthroscopic labral reattachment / capsular plication +/- rotator interval closure

- 1 recurrent subluxation and 2 with positive apprehension

 

Open revision

 

Levine et al Am J Sports Med 2000

- 49 shoulders treated with capsular shift +/- Bankart repair if needed

- all patients who had a traumatic redislocation had a good result

- only 67% of patients with atraumatic recurrent instability had a good results

 

Cases

 

Case 1

 

Recurrence of instability without trauma

- anchors very high

- into glenoid face

- MRI suggests remaining inferior bankart

- no bony deficiency, no HAGL

 

Failed Open Stabilisation APFailed Open Stabilisation LateralFailed Open Stabilisation CT AxialFailed Open Stabilisation CT Sagittal

 

Failed Open Stabilisation MRIFailed Open Stabilisation MRI 2

 

Case 2

 

Recurrent instability

- non recognised bony defect

- revised with Latarjet

 

Revison Shoulder Stabilisation CT Bony DefectRevision Shoulder Stabilisation Bony Defect 2Revision Stabilisation with Latarjet

 

 

 

 

 

Locked Glenohumeral Dislocation

Definition

 

A GH dislocation which has been missed for a significant period of time

- time period is arbitary

- > 3-6 weeks

 

Pathology

 

Humerus soft and osteoporotic

Significant soft tissue contractures

 

1.  Anterior / subcoracoid dislocation

 

Beware

- scarring to NV structures

- RC tears including SSC, especially > 40

- anterior glenoid wear / can have significant bone loss

- large engaging Hill Sachs / humeral head defects

 

2.  Posterior dislocation

- posterior glenoid wear

- reverse Hill Sach's / large anteromedial defects

 

Epidemiology

 

Anterior 41%

 

Posterior 59%

 

Aetiology

 

Multi trauma

Seizures

Poor patient mental function

 

History

 

Limitation ROM

History multi trauma / seizures

Previous treatment

- often have had inadequate X-rays

- extensive physiotherapy / injections

 

Examination

 

Usually some asymmetry

 

Some reduction ROM

 

Palpate humeral head anteriorly / posteriorly

 

X-rays

 

Scapular AP view

Scapular lateral

Axillary lateral

 

CT

 

Aids diagnosis and preoperative planning

 

Management

 

Non Operative

 

Indications

- elderly 

- minimal functional limitation

- significant medical issues

 

Only operate if significant clinical problems

- anterior more difficult than posterior to solve

 

Operative

 

Closed reduction

 

Issues

 

1.  Timing 

- has been successful up to 6-8 weeks

- most successful outcomes in literature < 4 weeks

 

2.  Humeral head impression

- if this is locked on glenoid, closed reduction is contraindicated

 

3.  May be unstable afterwards

- need further open procedure

- need careful postoperative monitoring

- regular xray surveillance

 

Chronic Anterior Dislocation

 

1.  Large Humeral Head Defect

 

Hill Sach's

- posterolateral defect

- manage according to size

 

Defect < 40%

 

A.  Elevate and Bone graft defect

- < 4 weeks in young patient

- adequate bone, salvageable cartilage

- posterior approach

- split deltoid / L shaped Infraspinatous tenotomy

 

B. Advance Infraspinatous +/- GT

- posterior approach

- < 20% IS alone

- if larger must also take GT

 

Defect > 40%

 

A.  Allograft

- young patient

- pre-op CT to estimate humeral head size

- appropriate sized femoral / humeral head

 

B.  Prosthesis

- often significant OA with long standing dislocation

- anterior glenoid deficiency

- older patient

- increase retroversion of humeral component

- may need to address anterior glenoid deficiency

 

2.  Glenoid Deficiencies

 

Indicated when > 20-25% anterior glenoid eroded

 

Bristow / Latarjet

 

Glenoid Reconstruction

- humeral head

- iliac crest

 

Glenoid Reconstruction Humeral HeadGlenoid Reconstruction

 

3.  Soft tissue deficiencies 

 

Always combine with anterior labral repair +/- inferior capsular shift

 

4.  Rotator cuff tears

 

Significant issue

- if massive cuff tear, may lead to chronic instability

- very difficult to treat

 

CASE 1

 

50 year old, missed locked anterior dislocation one year

- head severely mis-shapen

- missing 50% glenoid

- massive rotator cuff tear

 

Treatment

- open reduction

- shoulder hemiarthroplasty / humeral head used to bone graft glenoid / rotator cuff repair

- unfortunately rotator cuff repair failed, and developed recurrent instability

- option: Reverse TSR / fusion

 

Locked Anterior 1Locked anterior 2Locked Anterior 3

 

Locked anterior MRI 1Locked anterior MRI 2Locked anterior MRI 3

 

Locked anterior surgery 1Locked anterior surgery 2Locked anterior surgery 3

 

CASE 2

 

26 year old female

- ligamentous laxity, but no previous shoulder problems

- traumatic anterior shoulder dislocation

- leading to recurrent anterior subluxation

- had an arthroscopic anterior and posterior capsular plication

- shoulder now permanently dislocated anteriorly

- options: open posterior capsular release and latarjet / or fusion

 

Chronic anterior dislocation 1Chronic anterior dislocation 2Chronic anterior dislocation 3

 

Locked anterior 1Locked anterior 2Locked anterior 3

 

Chronic Posterior Dislocations

 

Approach

 

Standard DP approach

- manage SSC depending on operative plan for humeral head defect

- open capsule

- remove any fibrous tissue in glenoid

- use lever to reduce humeral head

- usually can ignore posterior capsular detachments

 

Manage humeral head / glenoid defects

 

See Posterior Shoulder Instability

 

1.  Humeral Head defects

 

Posterior dislocation

- anteromedial

 

Defects < 40%

 

A.  Disimpaction and bone graft

- < 4 weeks, young patient

- articular cartilage must be salvageable

- via anterior approach

 

B.  McLaughlin

- < 20%, SSC only

- < 40% transfer SSC + LT into defect

- secure with 2 x cancellous screws

 

Defects > 40%

 

A. Allograft

- young patient

 

B.  Hemiarthroplasty / TSR

 

2.  Posterior Glenoid Deficiency

 

May need posterior bone graft

 

Luxatio Erecta

Epidemiology

 

Rare, inferior shoulder dislocation

 

Aetiology

 

Forced abduction injury

 

Pathology

 

Shoulder is hyperabducted

- humeral shaft abuts the acromion

- humeral head is levered inferiorly

- tears inferior capusle

 

Head becomes locked inferior to glenoid

 

May button hole through inferior capsule

- becomes irreducible

- need open reduction

 

Has tear rotator cuff / GT fracture

 

Associations

 

Tear RC

GT fracture

AXN palsy

Thrombosis axillary artery

 

Clinical Presentation

 

Patient has shoulder abducted

- has elbow flexed

- elbow resting on head

 

Reduction

 

Conscious sedation

- increased abduction initially

- then adduct

 

Post Reduction

 

MRI

- assess RC / biceps

 

AXN

- usually recovers

 

 

 

 

Multidirectional Instability

DefinitionMDI Shoulder

 

Instability in at least 2 planes

- postero-inferior

- antero-inferior

- antero-postero-inferior

 

Epidemiology

 

Recognised as a common problem 

- often misdiagnosed

 

Most patients athletic

- average age 24 years (15 - 54 years)

 

Aetiology

 

1.  Inherent ligament laxity > 50%

 

2.  Repetitive overuse with capsular stretch 

- microtrauma

 

3.  Macro-trauma < 50%

 

Pathology

 

Collagen abnormality

 

Increased joint volume 

- 2° enlarged inferior axillary capsular pouch

- patulous anterior and posterior

 

Often attenuated, broad rotator interval

 

History

 

Often bilateral

 

Instability of other joints

 

Feeling of shoulder "slipping down" while carrying heavy loads

- inferior instability

 

Often recurrent subluxation with minimal trauma

- sleeping

 

Shoulder pain

- fatigue 

- impingement type pain with overhead activities

 

Examination

 

Ligamentous laxity 75%

 

Inferior instability

- Sulcus Sign +

 

Shoulder Sulcus Sign

 

Anterior instability

- anterior draw

- anterior load and shift

- anterior apprehension, positive Jobe's relocation

 

Posterior instability

- posterior draw

- posterior load and shift

- posterior apprehension / jerk test

 

Xray

 

Traction xray

- patient standing with 5-10 kg in each hand

- Shows inferior subluxation of head

 

DDx of Inferior displacement of head

 

Torn superior rotator cuff

Suprascapular nerve palsy

Deltoid atony eg CVA

Deltoid / axillary nerve palsy

 

Management

 

Non-operative

 

Mainstay of treatment

- operative results poor

 

Physiotherapy

 

Minimum 12/12

- initial shoulder strengthening

- strengthen 3 parts of deltoid, cuff & scapular stabilisers

- specific programme with rope & pulleys

- combined with education program

- ~ 90 % success

 

Operative

 

Principles

- never operate on voluntary dislocator

- MDI surgery less successful than surgery for unidirectional instability

- cannot perform isolated anterior surgery

- bristow procedures etc fail as capsule remains redundant 

- anterior surgery may displace head posteriorly

 

MDI with traumatic anterior bankart

- new symptomatic instability on a background of ligamentous laxity / MDI

- MRA diagnosis of anterior bankart

- is reasonable to operate on patient with new traumatic anterior instability with labral tear

- issue is whether to combine with capsular shift

 

Options for MDI

 

1. Neer and Foster inferior capsular shift

2. Arthroscopic capsular plication

 

1.  Open Inferior Capsular Shift ~ Neer & Foster 1980

 

MDI SubluxedMDI Reduced

 

Principle 

- detach capsule from neck of humerus

- shift capsule superiorly to obliterate the inferior pouch

- decrease joint volume

 

Technique

 

EUA

- to confirm diagnosis

 

Deltopectoral Approach / Axillary fold

 

SSC

- must divide SSC separate to capsule

- need to leave capsule intact

- make horizontal incision in inferior border of SSC

- at muscular aspect

- insert curved artery forcep between SSC and capsule

- will exit at rotator interval

- insert medial stay sutures x 2 (use different colour to differentiate from capsular sutures)

- make vertical incision on artery forcep to avoid injury to capsule

 

T shape capsulotomy of capsule

- vertical component on humeral insertion

- transverse component to midpoint glenoid

- mark with pen first

- make vertical component on articular margin

- place inferior and superior stay sutures

- make horizontal incision

- creates superior and inferior capsular flaps

 

Capsular Shift 1Capsular Shift 2

 

Inspect joint

- ensure no loose bodies

- repair bankart lesion if needed

 

Inferior capsular flap

- must sharp dissect capsule off inferiorly around humeral head

- protect AXN at all times

- do so by following articular margin around

- ER shoulder +++

- must get past 6 o'clock into posterior aspect

- check that traction on interior flap reduces inferior capsular pouch

 

Superior advancement inferior capsular flap

- tension on flap aimed at eliminating inferior pouch

- must reduce posterior capsular redundancy

- multiple 0 pull off stay sutures through flap and into remnant humeral tissue

- +/- anchors

- begin inferiorly, care with AXN

- cut and clip each sutures

- then tie all sutures togther at end

 

Capsular Shift 3Capsular Shift 4

 

Check ER

- arm adducted, check ER 45o

- arm abducted to 90o, check ER 45o

 

Superior flap sutured down over inferior flap

- again multiple 0 pull off sutures

- tie

- check ER as above

 

Check not too tight

- can dislocated posteriorly

 

Closure of RI

- check ER as above

 

Subscapularis tendon brought over & reattached to normal location

- check ER as above

 

Post op

- Arm immobilised in sling 6/52

- No sport for 9/12 

 

Results

 

Bigliani et al JBJS Am 2000

- 52 shoulders with open inferior capsular shift

- approach posterior or anterior depending on greatest instability

- 96% remained stable at average 61 months

- 60% excellent and 30% good results

- 70% athletes able to return to sport at same level

 

Ogilvie-Harris Br J Sports Med 2002

- contact athletes

- antero-inferior capsular shift in 37 with 3 recurrences (8%)

- posterior-inferior capsular shift in 16 with 2 recurrences (1 anterior / 1 posterior)(12%)

- 80% return to sport in antero-inferior capsular shift

- 75% return to sport in postero-inferior capsular shift

- only 17% return to sport if bilateral procedures

 

MDI Pre Capsular ShiftMDI Post Capsular Shift

 

2.  Arthroscopic

 

Technique

 

EUA

 

View via posterior and anterosuperior portal

- labrum is attached

- capsule very lax

 

Capsular laxity 1Capsular laxity 2Intact anterior capsule and labrum

 

Anterior plication

- use shaver to create capsular stimulation

- don't remove or resect capsule

 

Option 1

- pass through capsule, then through labrum
- inferior suture first

- take bite of anterior inferior capsule with suture passer

- advance suture passer

- then pass separately through anterior labrum at a more superior level

- tie

- repeat x 2

 

MDI Anterior Capsular PlicationMDI Anterior Capsular Plication 2MDI Anterior Capsular Plication 3

 

MDI 2 bites anterior capsuleMDI 3 x anterior capsular sutures

 

 

Option 2

- anchor in glenoid

- pass stures throught capsule and labrum

 

Capsular laxityCapsular plication with suture anchorsCapsular laxity post plication with suture anchor

 

Posterior plication

- camera inserted via anterior portal

- insert posterior cannula

- repeat inferior posterior sutures x 3

 

MDI Posterior capsular plication

 

May suture rotator interval if needed

 

Results

 

Baker et al Am J Sports Med 2009

- 43 patients average age 19 years

- 86% return to sport

 

3.  Thermal Capsular Shrinkage

 

Recognised as poor procedure

 

Results

 

Miniaci et al JBJS Am 2003

- 19 patients with MDI

- 9 recurrent instability

- 4 had parasthesia in AXN, one had deltoid weakness, all resolved

- worse results in posteroinferior compared with anteroinferior

 

Posterior

Posterior Dislocation

Chronic Posterior Dislocation APChronic Posterior Dislocation Lateral

 

Epidemiology

 

Rare 

- 2% of acute dislocations

 

Often missed

- < 1/ 52 25%

- < 6/52 25%

- < 6/12 25%

- > 6/12 25%

 

Aetiology

 

Usually secondary major trauma

- MVA

- Seizures

- ECT

- Electrocution

- Alcohol-related injuries

 

Examination

 

Loss of ER

 

Arm kept IR

- Hold arm across chest 

 

Beware of young patient with arm across chest & limited ROM

- don't think frozen shoulder only

 

AP Xray

  

1.  Light-bulb sign 

- globular head 2° IR

 

Posterior Shoulder Dislocation Light Bulb Sign

 

2.  Vacant Glenoid Cavity

- > 6 mm space between humeral head and anterior rim of glenoid

 

Posterior Shoulder Dislocation AP Non Concentric GHJ

 

Axillary Xray

 

Diagnostic

- humeral head posterior to glenoid

 

Look for reverse Hill- Sachs

 

Posterior Shoulder Dislocation Axillary Lateral

 

Scapular lateral

 

Can be missed if any obliquity to Xray

- centre of the humeral head must be centred on the Y / Mercedes

- Y is formed by coracoid anteriorly / scapular spine posteriorly / scapula body inferiorly

 

Posterior Shoulder Dislocation LateralPosterior Shoulder Dislocation Scapula Lateral

 

CT scan

 

A.  Confirms dislocation

 

Posterior Shoulder Dislocation Sagittal CTPosterior Shoulder Dislocation CT 1Posterior Shoulder Dislocation CT 2

 

B.  Quantifies humeral head defect 

- very important to decide management if locked / chronic / unstable

 

Humeral Head Defect

 

Quantification

- measured as a percentage of the articular surface

  

Case 1

 

CT Chronic Posterior Humeral Head DefectPosterior Shoulder Dislocation Anterior Hill Sachs

 

Case 2

 

Posterior Shoulder Dislocation Head Defect 1Posterior Shoulder Dislocaton Head Defect QuantificationPosterior Shoulder Dislocation CT

  

MRI

 

Chronic Posterior Shoulder Dislocation MRI AxialChronic Posterior Shoulder Dislocation MRI Sagittal

 

Management

 

Closed reduction

 

Beware

- injury more than 6 /52 ago

- large posterolateral defect locked on glenoid rim

- > 40% defect (will be unstable)

 

Technique

 

Consent for

- open reduction

- +/- bone grafting

- +/- McLaughlin procedure

 

GA

- arm adducted

- arm flexed to 90o

- increasing IR first to unlock head

- traction

 

Unstable closed reduction 

- may have to use gun slinger cast

- arm abducted 90o and ER

 

Post Reduction

 

Assess anterior Hill Sachs

 

Posterior Shoulder Dislocation Post Reduction Anterior Hill SachsReverse Hill Sach's

 

Open reduction

 

Indication

- failure closed reduction

- inability to maintain reduction in gunslinger

- chronic posterior dislocation

 

Technique

 

1.  Anterior deltopectoral approach

- reduce humeral head

 

2.  Address instability / manage anterior humeral head defect

 

Humeral head Defect Management

 

1.  HS < 25% 

 

Options

- treat non operatively if stable

- may be able to elevate and bone graft acutely in young patient

- +/- posterior labral repair

 

Reverse Hill Sachs less than 25 percent

 

2.  HS > 25%

 

Options

- transfer SSC +/- LT

- osteochondral allograft young patient

- hemicap / resurfacing older patient

 

Reverse Hill Sachs Defect greater than 25%

 

3.  HS > 40%

 

Options

- hemiarthroplasty / TSR (older patient)

- osteochondral allograft (younger patient)

 

Reverse Hill Sachs greater than 40 percent

 

SSC +/- LT transfers

 

Options

 

SSC transfer / McLaughlin

- makes defect extra-articular

 

SSC + LT / Neer modification

 

Indications

- best for small defects = 25%

- young patient

 

Problem

- may weaken IR

 

Osteochondral Reconstruction

 

Shoulder McLaughlin APShoulder McLaughlin Lateral

 

Reverse Hill Sachs AllograftReverse Hill Sachs Allograft 2

 

Results

 

Diklic et al JBJS Br 2010

- 13 patients with anteromedial defects between 25 and 50%

- all chronic / missed injuries

- open reduction

- SSC divided 1 cm from insertion, separated from capsule

- posterior labral repair / posterior plication if required

- femoral allograft inserted and fixed screws

- ER brace post op

- 9 patients pain free, 1 developed AVN, other 2 mild pain

 

Hemiarthroplasty / TSR

 

Indication

- older patient

- humeral defect > 40%

 

Issues

- may get recurrent posterior instability

- may have posteror glenoid bone defect

 

Technique

- anterior SSC Z lenthening

- posterior capsular plication +/- advancement IS / Tm

- glenoid poly insertion if posterior glenoid wear

- decreasing humeral head retroversion to 20o

- gunslinger post op for 6 weeks

 

Results

 

Sperling et al J Should Elbow Surg 2004

- 12 patients, average age 55 years, average 26 months since dislocation

- mix of hemiarthroplasty and TSR depending on state of glenoid

- some posterior plications performed

- 2 patients had recurrent posterior instability

- one patient had advancement of IS / Tm and posterior capsular plication

- one hemi was revised to TSR with plication

Posterior Instability

Definition

 

Patients usually complain of subluxation rather than dislocation

- rarely requires reduction

 

Different entity to acute posterior dislocation usually

 

Epidemiology

 

Rare

 

Aetiology

 

1.  Ligamentous laxity > 50%

- commonly associated with MDI

- posterior only 20%

- posterior & inferior 20%

- posterior / inferior & anterior 60%

 

2.  Trauma

 

A.  Repetitive microtrauma 

- common

 

B.  Macro-trauma 

- uncommon

- seizures

- electrocution

- ECT

- alcohol related injuries

- MVA

 

Pathogenesis

 

1.  Capsulo- ligamentous

 

A.  Reverse Bankart lesion 

- uncommon

- detached posterior labrum < 10%

 

B.  Capsular laxity

- much more common

 

C.  Posterior IGHL avulsion

- reverse HAGL

 

2.  Bony

 

A.  Humeral Head Defects  

- reverse Hill-Sachs lesion 

- defect in Ant humeral head

- seen in traumatic dislocations / chronic posterior dislocation

- can make humerus unstable

- compared with anterior Hill-Sachs which rarely does

 

CT Humeral Head Defect

 

B.  Posterior glenoid deficiency

- seen in traumatic / chronic dislocations

 

Posterior Glenoid DeficiencyPosterior Glenoid Deficiency Sagittal

 

C.  Humeral head / glenoid retroversion

 

Shoulder Posterior Instability Glenoid Retroversion

 

History

 

Must exclude voluntary dislocator

 

History of ligamentous laxity / other problems

 

Examination

 

Must assess for

- MDI / Ligamentous Laxity

- voluntary dislocator

 

Tender posterior joint line 

- fairly specific for OA rather than instability

 

ROM

- loss of ER (in locked posterior dislocation)

 

Ligamentous laxity

 

Sulcus sign

- indicates MDI

 

Anterior apprehension

- indicates MDI

 

Posterior stress test 

- supine

- adduct, forward flex and IR arm

- posterior force

- apprehension test

 

Load and Shift / Posterior Drawer

 

Altchek Grading

 

Grade 0       No translation

Grade 1+     Up to glenoid rim

Grade 2+     Beyond rim with spontaneous reduction

Grade 3+     Translation beyond rim without spontaneous reduction

 

CT

 

1.  Define extent of Hill Sach's lesion

 

2.  Glenoid bone defect

 

3.  Glenoid version

 

Posterior Instability Glenoid Retroversion

 

MRI

 

Posterior bankart lesion

 

Shoulder MRI Posterior Labral Tear

 

Posterior labral cysts

 

Shoulder Posterior Labral Tear with Cysts0001Shoulder Posterior Labral Tear with Cysts0002Shoulder Posterior Labral Tear with Cysts0003

 

Management

 

Non-operative

 

Not infrequently little functional problems

 

Prolonged initial physical treatment for all patients

- minimum 12 months

- treat similar to MDI patients

- Matson & Rockwood 80-90% success rate

 

Operative

 

Indications

- failed non-operative management

- moderate to severe disability

 

Contra-Indications

- MDI

- voluntary dislocator

- ligamentous laxity

- minimal functional impairment

 

Pathology

 

1.  Posterior Bankart lesion

 

Options

- arthroscopic / open reconstruction

 

Posterior Labral Tear

 

Failure / Bony Block Revison

- posterior approach

- detach infraspinatous

- expose capsule

- divide capsule medial to glenoid

- take 2 cm long x 1 cm thick iliac crest

- secure to glenoid with 2 x small fragment screws

- reattach capsule lateral to bony block

 

Failed Posterior Arthroscopic Shoulder Stabilisation0001Failed Posterior Arthroscopic Shoulder Stabilisation0002Shoulder Posterior Bony Block0001Shoulder Posterior Bony Block0002

 

2.  Capsular laxity

 

Options

- posterior capsular shift arthroscopic or open

- reverse Putti-Platt

 

Open capsular plication

 

Bigliani and Flatow July 1995

- 35 patients

- If primary operation 23 of 24 successful

- 89% stable at 5 yrs

 

Reverse Putti-Platt

 

Technique

- posterior approach

- posterior imbrication of IS & Tm 

- combine with posterior capsule imbrication

- shorten tendon 1cm = 20°

- limit IR to 20o

 

3.  Humeral Head Defect

 

Humeral Head Anterior Hill Sachs CT

 

1.  HS < 25% 

- leave

 

2.  HS > 25%

- transfer SSC + LT (McLaughlin)

- OC allograft

 

3.  HS > 40%

- hemiarthroplasty / TSR (older patient)

- OC allograft (younger patient)

 

4.  Posterior Glenoid Defects

 

Option

- posterior glenoid bone graft

 

Posterior Glenoid Bone BlockPosterior Bone Block CT

 

Results

 

Meuffels etal JBJS Br 2010

- 18 year follow up of 11 patients treated with posterior bone block

- 36% had had recurrent dislocation

- half would not have the surgery again

- all had evidence of OA

 

5.  Retroverted Glenoid Version / Static Posterir Shoulder Subluxation

 

Issue

- posterior shoulder subluxation > 65%

- shoulder OA

- young age

- glenoid osteotomy

 

Static Posterior Shoulder SubluxationGlenoid Retroversion SPSSSPSS MRISPSS Calculation

 

Option

- posterior opening wedge glenoid osteotomy

- rarely indicated & technically hard

 

Indication

- congenital retroversion of glenoid > 30o

 

Technique

- only 5 mm medial to glenoid rim otherwise injure SS nerve

- must prevent penetration of glenoid

 

Complications

- anterior impingement of subscapularis on coracoid causing pain

- anterior subluxation of humeral head

Surgical Techniques

1.  Arthroscopic Posterior Bankart Repair +/- Capsular Plication

 

Posterior Labral TearPosteior Labral Repair

 

Technique

 

Posterior Portal

- make slightly inferior and lateral compare to normal

- inspect joint

- place anterior portal +/- ASL portal

 

Remove cameral and place thorough anterior portal

- place 8 mm cannula through posterior cameral portal (over switching stick)

 

Often need second portal lateral and inferior to place inferior anchor

- can use simple stab incision here

 

Assess labrum and capsule

- repair posterior bankart

- plicate redundant / patulous capsule

 

Results

 

Kim et al JBJS Am 2003

- 27 patients with unidirectional posterior instability

- all with labral injuries, most with capsular laxity

- all had arthroscopic posterior labral repair and capsular shift

- only one recurrence

 

Pennington Arthroscopy 2010

- 28 athletes with pure posterior labral pathology

- 93% return to sport

 

Bradley et al Am J Sports Med 2006

- 91 athletes with 100 shoulders with unilateral posterior instability

- variations of suture anchor labral repair / anchor capsulolabral repair / capsular plication sutures

- 30% posterior labral tear, 43% patulous capsule with no labral pathology

- remainder combination injuries including partial labral tears

- 8% failure rate, all with capsular laxity

- patients had evidence of chondrolabral retroversion

 

2.  Open Posterior Capsular shift 

 

Open Technique

 

Position

- lateral

 

Incision

- vertical incision

- posterior axillary fold

 

Shoulder Posterior Approach

 

Superficial dissection

- split deltoid to expose infraspintous

- elevate IS off capusle

- L shaped incision infraspinatous after tagging sutures medial

- T shaped capsulotomy of capsule for posterior shift (vertical limb on humeral insertion)

 

Dangers

- no more than 1.5cm medial to glenoid to protech SS nerve

- axillary nerve through quadrangular space below Tm

 

Procedure

- labral detachment reattached if present

- graft glenoid with bone from spine / iliac crest if defect

- inferior capsule shifted superiorly

- reinforced with superior limb of capsule

- may augment with IS tensioning

 

3. Posterior Glenoid Osteotomy

 

Reserved for in setting of severe posterior retroversion with instability

 

Posterior glenoid osteotomy

 

 

 

 

 

Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2

 

Technique

 

1. Establish portals

 

A.  Posterior portal for viewing

 

B.  Anterior portal

- need to keep low and away from biceps, otherwise difficult to get around biceps

- for suture passage, if in combination with bankart repair often use AI portal instead of AS

 

SLAP repair anterior portal

 

C.  Anterosuperolateral portal / Wilminton for insertion of anchors

- insert spinal needle first

- anterolateral border acromion

- needs to be close to acromion to get angle over humeral head

- check with needle

- need best angle to insert anchors to anterior and posterior aspect of biceps

- passes through supraspinatous

- use knife to cut in line with fibres

- insert portal

 

SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals

 

2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone

 

Shoulder SLAP Preparation Base

 

3.  Anchors

 

Drill and insert via Wilminton portal

Usually 3 anchors is a minimum

 

Technique

- insert anchor

- suture through each cannula

- limb through W portal will be the suture limb that is passed

- suture passer through anterior portal (right angled for left shoulder)

 

SLAP Anchor InsertionShoulder SLAP Repair Suture Management

 

Anterior anchor

- best to pass the suture passer above the biceps to get good bite

- retrieve sutures and tie from port of Wilmington

 

SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2

 

SLAP Anchor 1SLAP Tie anterior anchor

 

Posterior 2 anchors

- pass suture passer under biceps

 

SLAP Vertical MattressSLAP Second Anchor

 

SLAP third anchorSLAP 3 anchor repair

 

Can suture Portal of Wilminton if desired

 

Portal WilmingtonWilminton Repair 1Wilminton Repair 3

 

4.  Dfficult posterior anchors

 

Camera through anterior / anterosuperiorlateral portal

 

A.  Place anchor through posterior portal

- does not always give good angle

 

SLAP repair posterior portal

 

B.  Trans infraspinatous Portal

 

SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair

 

Biceps Tenodesis

Options

 

Arthroscopic

- intra-articular

- suprapectoral

 

Open

- suprapectoral

- subpectoral

 

A.  Arthroscopic Intra-articular

 

Biceps Tenodesis Intra articular

 

Concept

- suture biceps to superior capsule using figure 8 no 2 non absorbable

 

Technique

- anterior portal + portal of Wilmington

- debride capsule and biceps with shaver so will heal

- use curved suture passer with no 1 PDS

- suture shuttle no 2 fibre wire

- divide 90% biceps insertion so will rupture in time

- allows healing of biceps to capsule

 

Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture

 

Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut

 

Attempt Figure 8 Suture Configuration

 

Biceps Tenodesis Step 1Biceps Tenodesis Step 2

 

B.  Arthroscopic Suprapectoral Technique

 

1.  Secure Biceps Tendon - allows tensioning and prevents losing tendon

 

A.  Birds Beak Passer with 2 ethibond loop

- pass loop through intact tendon at entry through RC interval

- retrieve loop out through portal and lock

- this gives strong hold on tendon

 

B.  Pass 18 G spinal needle through biceps tendon

- thread 1 PDS or nylon

- retrieve both suture ends via portal in rotator interval

- secure with half hitches

- pass 1 loop of PDS about entire tendon and tie again

 

Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon

 

2.  Resect tendon with electrocautery at insertion

 

Arthroscopy Biceps Tenotomy

 

3.  Make portal over biceps interval into subacromial space

- release biceps tendon with electrocautery or arthroscopic scissors

 

4.  Secure tendon

- make drill hole

- insert tendon

- secure with biotenodesis screw

- multiple techniques with specifically designed equipment

 

C.  Open Technique for Intact Biceps

 

1.  Divide biceps arthroscopically

- may wish to place stay suture first to avoid retraction

- biceps normally has vinculae preventing complete retraction into arm

 

2.  Suprapectoral

- deltoid split

- between anterior and middle parts

- find biceps in groove

- pull out of wound and whip stitch with heavy suture

- drill appropriate size tunnel for fixation screw

- multiple biceps tenodesis devices

- push the tendon into the hole, then fixate with screw

 

3.  Subpectoral

- medial incision in arm

- below inferior edge of pectoralis major

- find biceps tendon

- whip stitch

- pass through drill holes / secure with screw / secure with anchor

 

Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis

 

D.  Open Technique for Ruptured LHB / Popeye in young patient

 

1.  Locate biceps

 

Options

 

A.  Suprapectoral

- best to make deltopectoral approach

- biceps may be futher retracted

 

B.  Subpectoral approach

 

2.  Fixation

SLAP lesion

DefinitionMRI SLAP Tear

 

Superior labrum anterior & posterior

 

Injury to superior part of glenoid labrum involving region of biceps tendon insertion

 

Epidemiology

 

2 groups

 

1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability

 

2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis

 

Aetiology

 

Three mechanisms

 

1.  Compression force applied to GHJ

- FOOSH

- commonest

- arm in abduction & forward flexion

- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression

 

2.  Traction on Arm

- sudden pull on arm

- grab while falling

 

3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading

 

History

 

Pain with overhead activities

 

Catching or popping with overhead activities

 

Acute trauma

 

Mimics impingement

 

Examination

 

Speed's Test 

Yergason's Test

 

O'Brien's test

 

Causes impingement of biceps on anterosuperior labrum

 

1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain

 

2.  Relieved when same again but with ER

- i.e. no pain with thumbs up

 

McMurray's Shoulder test

 

Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click

 

MRA

 

See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant

 

MRI Slap with SS tearMRI Anterior Bankart

 

Supralabral ganglion cyst

- associated with posterior SLAP tears

 

Normal Arthroscopy

 

Normal Biceps Insertion

 

Arthroscopic Classification Snyder

 

Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 

 

Arthroscopy Meniscoid Biceps Insertion

 

Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   

 

Subtypes

- anterior

- posterior

- anterior and posterior

 

SLAP arthroscopyShoulder Scope SLAP Type 2

 

Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid

 

Shoulder Scope Type 3 SLAP

 

Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear

 

Type 4 SLAP Tear extends partially into bicepsSLAP Type 4

 

Type 5 - 7 added by Gartsman

 

Type 5
- SLAP 2 with anterior bankart extension

 

Type 6

- SLAP 2 with free flap of meniscal tissue

 

Type 7

- Slap 2 with anterior bankart extension and into MGHL

 

Normal Variations of the Superior Labrum

 

The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair

 

Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion

 

Davidson et al Am J Sports Medicine 2004

- described normal variations

 

1.  Triangular

 

2.  Bumper

- lump of fibrous tissue

 

3.  Meniscoid

- labrum extends down over glenoid face

 

Management

 

Non Operative

 

Trial

- physio

- HCLA

 

Operative

 

Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy

 

Options

 

1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy

 

Issues

 

1.  Older patient with RC tear and SLAP

 

Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group

 

2.  Repair v Tenodesis Type II SLAP

 

Boileau et al Am J Sports Med May 2009

- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)

- repair group 40% satisified, 20% returned to previous level of sport

- tenodesis patients 93% satisified, 87% return to previous level of sport

 

Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

- this was higher (92%) if athlete described a discrete traumatic event

 

3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist

 

MRI SLAPMRI Anterior Bankart

 

Management Algorithm

 

Type 1

 

Debride labrum

 

Type 2

 

A.  Arthroscopic repair

 

B.  Tenotomy / tenodesis

 

Type 3

 

Debride bucket handle labrum

 

Type 4

 

Remove labral flap

 

Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis

 

Types 5 - 7

- associated with instability

- repair as per treatment of instability

Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps

 

LHB primary function is humeral head depressor

 

Also accelerate / decelerate arm in overhead sports

 

Problems

 

Biceps problems usually occur with other pathology 

- rotator cuff / instability

 

3 main problems

 

1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture

 

Rupture

- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps

 

2.  Instability

 

Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament

 

Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear

 

Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears

 

3.  Disorders of the origin (SLAP)

 

4.  Hourglass Biceps

 

Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis

 

Anatomy

 

Origin 

- from postero-superior labrum and supraglenoid tubercule

 

Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament

 

Examination 

 

Tenderness over biceps tendon crucial

 

Rupture

- Popeye appearance

 

Popeye Sign BicepsPopeye Biceps

 

Speed's

- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness

 

Yergason's

- elbow flexed and pronated

- resist supination

- pain over LHB

 

O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up

 

MRI

 

Normal

 

MRI Enlocated Biceps Tendon

 

Tendonitis

 

Biceps Tendonitis MRI

 

Tendonosis / thickening

 

Biceps Tendinosis MRI

 

Medial Subluxation

 

Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC

 

Arthroscopy 

 

Normal

 

Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit

 

Mild Tendonopathy

 

Biceps Tendonopathy Grade 2 Arthroscopy

 

Moderate Tendonopathy

 

Shoulder Biceps Moderate Tendonopathy

 

Severe Tendonopathy

 

Biceps Tendonopathy ArhroscopyBiceps Tear near complete

 

Dislocated Biceps in Presence of complete SSC Rupture

 

Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon

 

Management

 

1.  Tendonitis

 

Non Operative

 

As per rotator cuff / impingement

- HCLA

- physio

 

Surgical Options

 

1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament

 

2.  Tendon Fraying / Tendinosis / Rupture

 

Grade tendon integrity

 

I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture

 

Management Strategy

 

I & II

- SAD & debride tendon 

 

III & IV

- SAD & biceps tenodesis / tenotomy

 

Tenotomy v Tenodesis

 

Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another

 

Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores

 

Tenotomy

 

Popeye deformity

 

Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men

 

Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis

 

Strength

 

Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength

 

Tenodesis

 

Indications

- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)

 

Issues

- screw prominence / pain

- failure of fixation

 

Options

- arthroscopic

- open

- see techniques

 

Arthroscopic

 

Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral

 

Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony

 

Open

 

Suprapectoral or subpectoral

 

Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury

 

3.  Subluxation

 

Issues

 

Usually medial from SSC tear

- must manage LHB or SSC repair will fail

 

Options

 

1.  Tenodesis / Tenotomy + SSC repair

 

2.  Stabilisation + SSC repair

 

Issue

- can get stenosed painful tendon  

 

Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US

 

 

 

 

 

 

Miscellaneous

Axillary Nerve Lesions

Anatomy

 

Terminal branch of the posterior cord

- lateral to radial nerve

- behind axillary artery

- runs over inferolateral border of SSC

- enters quadrangular space

 

Quadrangular space

- SSC superiorly anterior

- T major inferior

- T minor superiorly posterior

- long head triceps and humerus

 

Divides into anterior and posterior branches

 

Axillary Nerve Sagittal MRI 1Axillary Nerve Sagittal MRI 2

 

Anterior branch

- curves around SNOH

- deep to deltoid

- 4-7 cm inferior to corner acromion

- supplies anterior and middle portions deltoid

 

Posterior branch

- supplies T minor and posterior deltoid

- sensory branch

 

3 distinct fascicles

- T minor

- deltoid (supero-lateral)

- superior lateral cutaneous branch

 

Aetiology

 

1.  Traumatic

2.  Iatrogenic

3.  Quadrilateral Space Syndrome

4.  Brachial Neuritis

5.  SOL

 

1.  Traumatic

 

A. Shoulder Dislocation

- 10-20% incidence post dislocation

 

Blom et al Acta Chir Scand 1970

- 9 complete and 15 partial lesions

- all recovered within 1 - 2 years

 

Gumina JBJS Br 1997

- high rate in elderly > 40 (50%)

- all recovered by 3 years

- high rate of RC (20%)

 

B. Proximal Humeral fracture

 

C. Brachial Plexus injury

- rarely isolated

- in conjunction with other injuries

- upper trunk

 

D.  Blunt trauma to deltoid

 

2.  Surgery

 

A.  Deltoid-Splitting approach

- lies 5cm lateral to anterolateral corner of acromion

 

B.  Deltopectoral approach

- undue care at inferior level of SSC

 

3. Quadrilateral space syndrome

 

Mechanism

- Compression in position ER and abduction

 

Symptoms

- get pain and paraesthesia in shoulder 

- can have chronic dull ache

 

Signs

- usually no deltoid atrophy or sensory changes

 

Investigation

 

EMG

- normal

 

Angiogram

- shows compression of posterior humeral circumflex artery with less than 60o abduction

 

MRI

- may shows changes in deltoid and Tm

 

Mangement

- usually just observation

- occasionally need to decompress scar tissue or fibrous band

 

4.  Parsonage-Turner Syndrome

 

Brachial neuritis

- spontaneous development severe shoulder pain

- then develop loss of motor function

- usually also LTN, SS nerve, but occasionally isolated

 

Management

- can treat with steroids

- usually good prognosis

 

5.  Nerve compression from mass effect

 

Cause

- aneurysm, tumour

 

History

 

No history trauma

- suspect mass effect / quadrilateral space syndrome / brachial neuritis

 

Pain then loss of function

- suspect brachial neuritis

 

History dislocation

 

Examination

 

Deltoid Wasting

 

Wasting Deltoid

 

Weakness of shoulder abduction

 

Numbness in Regimental patch 

- variable

 

DDx

 

1.  Upper trunk injury / root injury (C5/6)

- will also have injuries to

 

A.  SS nerve

- IS / SS

- remember dislocation may cause RC tear

 

B.  Subscapularis

 

C.  Biceps

 

2.  Posterior cord injury

- will also have injuries to

 

A.  Radial nerve

- triceps, WE, FE, thumb extension

 

B.  Thoracodorsal

- Lat Dorsi

 

C.  Upper and lower subscapular

- SSC

 

NCS / EMG

 

Diagnose higher lesion

- reference point for recovery

 

MRI

 

Mass lesions

Atrophy of T minor

Assess RC 

 

Operative Management

 

Indications

- no clinical or NCS / EMG sign of recovery at 6/12

- open wounds / stab wounds

 

Timing

 

Best results 

- reinnervation must occur before one year

- otherwise get degeneration of NMJ

- i.e. surgery must occur by 9 months

 

Options

 

No muscle transfer for deltoid

- nerve repair

- neurolysis

- nerve grafting

- nerve transfer

 

1.  Neurolysis

 

Indications

- if nerve intact but encased in scar or compressed by fibrous bands

 

Technique

- identify nerve

- use nerve stimulator intra-operatively

- stimulation of nerve will cause muscle contraction if intact

- uncommon

 

2.  Neurorrhaphy 

 

Indication

- laceration

 

Technique

- direct repair of laceration

- if in first few weeks

 

3.  Nerve grafting

 

Indications

- neuroma usually at or in quadrilateral space

 

2 Incision Technique

 

Sural nerve graft

- anastomose anteriorly, then pass through

- anastomose posteriorly

 

Lateral decubitus

- access anterior and posterior shoulder

- allows sural nerve harvest

 

Deltopectoral approach

- release half or all of P major (leave cuff for repair)

- must release conjoint tendon and P minor

- do so 1cm from origin

- expose axillary, radial and MCN

- use nerve stimulator to ensure nerve not working

- identify and protect axillary artery and vein

- if deltoid active, neurolysis

 

Identify neuroma

- if deep

- posterior approach to shoulder

 

Posterior vertical incision

- lateral border acromion to posterior axillary crease

- mobilise inferior border deltoid superiorly

- find nerve as exits quadrilateral space

- identify deltoid fascicle using nerve stimulator

 

Results

 

Allnot Int Orthop 1991

- 23/25 isolated sural nerve grafting achieved M4 or M5 strength

 

4.  Neurotisation / Nerve transfer

 

Concept

- use branch of radial nerve

- transfer into motor branch axillary

- single incision

 

Technique

- posterior longitudinal approach to arm

- find AXN under wasted deltoid, exiting above T Major

- identify anterior branch of AXN going into muscle

- ensure not branch to T minor or sensory branch

- develop interval between long and lateral heads

- find radial nerve in groove between medial and lateral heads

- will be exiting below T Major between long and humerus

- harvest branch to long or medial head triceps

- long may be better as has two sources nerve supply and less functional impairment

- check with nerve stimulator

- repair with 9.0 nylon under microscope

 

Results

 

Leechavengvongs et al J Hand Surg Am 2003

- all 7 patients had M4 power

- 5 excellent and 2 good results

- no demonstrable loss of elbow extension power

Constant Shoulder Score

 

Subjective Assessment 35 points

 

Pain

 

ADLS

- work

- recreation

- sleep

 

Ability to work at specific level

- waist

- chest

- neck

- head

- above head

 

Objective Assessment 65 points

 

Flexion

 

Abduction

 

ER

 

IR

 

Strength

Pectoralis Major Rupture

Aetiology

 

Usually related to sporting activities including weight lifting

- bench press most common 

- higher risk with steroid use

 

Epidemiology

 

Peak age 20 - 40

 

Often unrecognised

 

Classification

 

Site

- intra-muscular

- MT junction

- tendon avulsion

- 2:1 tendon avulsions compared with musculotendinous junction

 

Partial or complete

 

Sternal / clavicular heads or both

 

Anatomy

 

Clavicular head

- medial clavicle and upper sternum

- inserts at lowermost aspect of biciptial groove

 

Sternal head

- sternum, aponeurosis external oblique and costal cartilages of first 6 ribs

- inserts at uppermost aspect of bicipital groove

 

Insertion

 

2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa

 

Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head

 

Nerve supply

 

Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head

 

Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor

 

Actions

- powerful adductor, flexor and internal rotator

 

History

 

Usually recall incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising

- only later when it settles is the cosmetic and functional deficiency apparent

 

Acute Pectoralis Major Tear

 

Examination

 

Asymmetry chest wall

 

Pectoralis Major RupturePectoralis Major Tear Chronic

 

Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction

 

Pectoralis Ruture Palpable Cord

 

Resisted adduction is weak

- hand on hip

- feel tendon insertion

 

MRI

 

Useful in the acute setting

 

Will also identify site of rupture and amount of retraction

 

Management

 

Non Operative

 

Indications

- partial tears

- muscle belly tears

- elderly

 

Operative

 

Results

 

Pochini et al Am J Sports Med 2010

- 10 operative cases (70% excellent, 20% good, 10% poor)

- 10 non operative (20% good, 50% fair, 40% poor)

- strength in non operative group 50% of other arm

 

Timing

 

Chronic ruptures

- best to repair within 8 weeks

- have been successful repairs from 3 months up to 13 years

 

Chronic

- may wish to have allograft / achilles tendon available

- especially needed if tendon has retracted beyond nipple line

 

Technique

 

Deltopectoral approach / axillary fold incision

 

Anterior lamina fibres of clavicular head are usually intact

- pectoral fascia also usually intact

- blunt dissection medially under clavicular head to find sternal head

 

Repair

 

1.  Make trough in bone lateral to biceps tendon with burr

- Krackow suture in tendon with no 5 non absorbable

- repair through drill holes

- +/- suture anchors

- + / - direct suture of MT junction

 

Pectoralis Major Repair 1Pectoralis Major Repair 2Pectoralis Major Repair 3

 

2.  Foot print technique

- roughen area of insertion lateral to LHB / osteotome

- insert 3 double loaded anchors in V formation ( 2 lateral and one medial)

- pass through tendon and suture down

 

3.  Allograft reconstruction

- fascia lata / tendo achilles

- pass graft through pec major

- double over and insert into bone tunnel

 

Post op

- sling 6 weeks

- ROM 6 weeks

- strengthening at 3/12

 

Complications

 

Infection

- higher than normal risk due to proximity to axilla

 

Humerus fracture

- case report with bone trough

 

LHB rupture

- case report

 

Re-rupture

- most common

- up to 7%

 

 

 

 

 

 

Shoulder Xrays

AP Shoulder

 

Technique

- in plane of thorax

- oblique of GHJ

 

Shoulder AP Xray

 

AP in plane of scapula

 

Grashey

- angle 45o lateral

- allows estimation of glenohumeral space

 

AP Plane Scapula

 

AP IR / ER

 

Demonstrates Hill Sach's and other humeral head morphology

 

Scapular lateral

 

Patient erect

- affected shoulder against plate

- rotate other shoulder 45o out of way

- beam aimed along spine of scapula

 

Scapular LateralScapula Lateral Posterior Shoulder Dislocation

 

Axillary lateral

 

Patient seated

- arm abducted

- plate under axilla

- beam angled down towards shoulder

 

Axillary Lateral XrayAxillary Lateral Posterior Subluxation

 

Supraspinatous outlet view

 

For acromial morphology and impingement

 

Similar to scapular lateral

- tilt beam caudal 10o

 

Supraspinatous Outlet View

 

West Point View

 

Variation axillary lateral

- tangential view anterior / inferior glenoid 

- for bony bankart

 

Patient prone with arm hanging off bed

- plate superior to shoulder

- camera 25° cephalad to horizontal / 25° to long axis body

 

Westpoint view Hill Sachs

 

Garth View / Apical Oblique

 

True AP with 45o caudal tilt

- to show anterior / inferior capsule 

- bony bankhart / Hill Sachs

- standing with plate behind joint

- 45° caudal tilt / 45° in coronal

 

Garth XrayShoulder Garth View

 

Stryker Notch view

 

Patient supine with cassette posterior to shoulder

- hand on head, elbow straight up

- beam 10o cephalic aiming at corocoid

 

Demonstrates Hill-Sach's

 

Stryker Notch View Hill Sachs

 

Zanca view

 

ACJ

 

Patient erect with cassette behind shoulder

- aim beam at ACJ 10 - 15o cephalic

- half strength to not overexpose ACJ

 

Zanca View

 

Serendipity view

 

SCJ

 

Technique

- prone with cassette under chest

- aim beam 40o cephalic

 

Sternoclavicular Joint Xray 1Sternoclavicular Joint Xrays 2

 

 

 

 

 

Sternoclavicular Pathology

 

Condensing Osteitis

 

Epidemiology

- seen in women over 40

 

Xray

- sclerotic and overgrown

 

Condensing Osteitis Xray

 

CT

 

Condensing Osteitis CT 2Condensing Osteitis CT

 

NHx

 

Sng Ann Acad Med Sing 2004

- follow up of 9 patients mean 34 months

- pain reduced over time

 

Management

 

Refractory

Will resolve with time

 

Options

- HCLA injection

- excision

 

Friedrich's Disease

 

Very rare condition seen in young adults

- AVN of sternal end of clavicle / occasionally lateral end

- pain and swelling

- ESR may be raised

- irregular sclerotic appearance on xray

- rarely requires excision

 

Sternoclavicular Hyperostosis

 

Bilateral condition

- ossification of sternoclavicular ligaments

- may lead to solid ossification with restriction of shoulder motion

- associated with pustules and elevated Alk Phos

 

Osteoarthritis

 

Sternoclavicular OA

 

SCJ OA MRI 1SCJ OA MRI 2

 

Options

 

1.  Intra-articular cortisone

2.  Fusion

 

 

Suprascapular Nerve

Anatomy

 

C5, 6 from Upper trunk

 

Posterior triangle

- arises upper trunk and passes backward through posterior triangle

- under belly of omohyoid

- deep to trapezius to the suprascapular notch

 

Suprascapular Ganglion Coronal MRI

 

Runs through suprascapular notch

- under superior transverse scapular ligament

- suprascapular artery and vein run over this ligament

- supplies SS 1 cm after passing under ligament

- give articular branch to the shoulder

 

Suprascapular Nerve Sagittal MRI 1Suprascapular Nerve Sagittal MRI 2

 

Passes around lateral border spinous process / Spinoglenoid notch

- under spinoglenoid ligament

- inferior transverse scapular ligament

- supplies IS

 

Motor

-  supplies supraspinatus & infraspinatus

 

Sensory

- ACJ, GHJ

- CA and CH ligaments

 

Sites of Compression / Injury

 

Suprascapular notch

- weakness wasting SS & IS

 

Causes

- trauma most common / driect blow / clavicle or scapula fracture

- iatrogenic / excessive rotator cuff release

- athletes / repetitive overhead motion

 

Spinoglenoid notch

- weakness wasting IS

 

Causes

- spinoglenoid cyst associated with superior labral tear / horizontal cleavage / acts as one way valve

- posterior approach to shoulder - > 1 cm medial to glenoid neck

- posterior shoulder OA causing a cyst

 

History

 

Pain at back of shoulder

Weakness

 

Examination

 

Weakness

 

Atrophy SS/IS

 

Atrophy of IS alone

 

DDx

 

Rotator Cuff tear

 

MRI 

 

1.  Spinoglenoid cyst / labral tear

- may be better seen with MRA

 

Spinoglenoid cyst Coronal MRISpinoglenoid Cyst Sagittal MRISpinoglenoid Cyst MRI Axial

 

2.  Atrophy of SS / IS

 

Spinoglenoid Cyst Infraspinatous Fatty Atrophy

 

3.  Exclude cuff tear

 

EMG 

 

Demonstrate denervation SS/IS or IS alone

 

HCLA

 

Inject SS nerve at suprascapular notch

 

Management

 

Non Operative

 

Reasonable if no ganglion cyst

- a neuropraxia which usually resolves

- avoid overhead activities if possible

- 6 - 9 months

 

Operative

 

Spinoglenoid Cyst

 

1.  Secondary to superior labral tear

 

Majority of cases

  

A.  Cyst Decompression + Arthroscopic labral repair

 

Technique

- identify horizontal cleavage tear

- decompress throught tear

- repair labrum

 

Posterior Labral Tear Cyst 1Posterior Labral Tear Cyst 2Posterior Labral Tear Cyst 3

 

Posterior Labral Tear 1Posterior Labral Repair 2Posterior Labral Tear 3

 

Piatt et al J Should Elbow Surg 2002

- excellent results

 

B.  Arthroscopic Labral Repair without cyst decompression

 

Schroder et al JBJS Am 2008

- 42 patients

- posterior labral repair without cyst decompression

- cyst resolved in 88% on MRI and smaller in remainder

- all patients satisfied with outcome

 

2.  Spinoglenoid Cyst without labral tear

 

Options to decompress cyst

- ultrasound drainage / not always effective but may be worth a try intially

- posterior approach

- arthroscopic glenohumeral approach / posterior capsulotomy

- subacromial approach / between supraspinatous and infraspinatous

 

Results

 

Werner et al Arthroscopy 2007

- posterior capsulotomy above IGHL with decompression of cyst with shaver

 

Posterior Shoulder Capsulotomy to decompress cyst

 

Ghodadra et al Arthroscopy 2009

- subacromial space

- identify spine of scapula

- dissect between infraspinatous and supraspinatous

- accessory posterior portal, retract IS and nerve

- decompress with shaver

 

Shoulder Subacromial Space Spinous ProcessSubacromial Spinous Process 1

 

Suprascapular Notch Impingement

 

Decompression / Division of Suprascapular ligament 

 

Indication

- weakness atrophy of SS and IS without cuff tear

- massive irreparable cuff tear with intractable pain

 

Options

- open

- arthroscopic

 

Results

 

Lafosse et al Arthroscopy 2007

- 10 patients with clinical and EMG evidence of suprascapular nerve compression

- no complications

- good clinical outcome in all patients

 

Open Technique

- incision along spine of scapular

- sharply elevate trapezius off spine off scapula

- SS reflected inferiorly to expose notch

- preserve superior NV bundle

- suprascapular artery lies above ligament, (branch of Subclavian Artery)

- divide ligament

 

Arthroscopic Technique

 

Standard posterior portal

- subacromial portal to debride cuff and identify base of coracoid as landmark

- find coracoid by following CAL to it

- feel hard bony prominence

 

Anterolateral working portal

- need to be able to work lateral to medial along anterior aspect of humeral head

 

Dissection

- clear space medial to coracoid along subscapularis

- identify the conoid ligament attaching to the base of the coronoid

- medial to this is fatty area with THL

 

SSN Release CoracoidSSN Release Coracoid and CHL

 

Suprascapular portal / accessory Nevasier

- 7cm from posterior edge of acromion

- insert blunt instruments posteriorly from suprascapular portal

- pass under clavicle

- elevates supraspinous muscle

- use blunt trochar to dissect area

 

Anatomy

- will usually see the artery passing over the top of the THL 

- be careful as this runs from subclavian

- can get torrential bleeding

 

Conoid Ligament  SSA over THLSuprascapular artery and transverse scapula ligament

 

Identify transverse ligament

- identify SSN passing under

- divide TSL with scissors from posterior ACJ portal

- whilst retracting SS artery with probe from SSN portal

 

SSN release Divided THLSSN Release Divided TSL

Thoracic Outlet Syndrome

Definition

 

Symptoms & signs due to compression of brachial plexus & /or subclavian vessels at root of neck

 

Epidemiology

 

80% 30-50 years 

 

F:M = 2:1 

 

Incidence

 

Uncommon

 

Anatomy

 

Thoracic Outlet forms communication at root of neck 

- for passage of nerves and vessels from mediastinum to axilla 

- vein is anterior to Scalenus Anterior

 

Boundaries

 

Anterior:  Scalaneus Anterior

Posterior: Scalaneus Medius

Floor:      First Rib

Roof:       Prevertebral fascia & clavicle

 

Aetiology

 

Bony / muscular / ligamentous compression of neurovascular bundle at Thoracic Outlet

 

Bony

 

1.  Cervical Rib

- 5 / 1000 

- only 10% of cervical ribs are symptomatic

- 10% of TOS have cervical rib

 

Varies from 

- enlarged TP 

- complete developed with cartilage uniting it to cartilage of 1st thoracic rib 

 

2.  1st Thoracic Rib

-  abnormal curve 

-  increased size or shape

 

3.  Clavicle

-  posterior fracture callus 

-  abnormal shape / malunion

 

Musculo-ligamentous

 

Most important cause

 

1.  Fibrous Band

 

Cervical rib joined to 1st rib by congenital fibrous band 

-  elevates lower part of brachial plexus 

-  makes it more susceptible to scissor compression by clavicle from above 

-  9 variants recognised

 

2.  Scalenus Muscles

 

Abnormal insertion 

Decreased size of cleft between S Anterior & S Medius

 

Other

 

Trauma

- Precipitates condition in 2/3

 

Posture

- shoulder sags with middle age 

- hyperabduction in sleep

- scapular winging secondary to trapezius palsy

 

Occupational

- hyperabduction of shoulders (painters, welders) 

- pressure (backpacks, soldiers)

 

Classification

 

1. Neurogenic

 

Compression of brachial plexus alone 

-  usually lower trunk C8,T1

-  most common 95%

 

2. Vascular

 

Compression of subclavian blood vessels alone 

- usually vein obstruction 

- occasionally arterial insufficiency 

- rare 2%

 

3. Combined

 

Compression of both nerves & vessels 

- rare 3%

 

Symptoms

 

2° compression of Plexus > Vessels

 

Pain

-  intermittent

-  suprascapular area and neck

-  may be whole arm

-  more common medial arm & ulnar forearm 

-  radiates to neck 

 

Worse after activity

- overhead

- carrying heavy weight

 

Paraesthesia

- C8 & T1 (mainly ulnar nerve distribution)

- may be whole arm

 

Weakness

- most noticeable is grip

 

Venous

- duskiness & cyanosis of hand 

 

Arterial

- cold, pale hand & forearm

- Raynaud's 

 

Signs

 

Pain from percussion or constant thumb pressure in supraclavicular region over plexus

 

Listen for bruit / compare arm BP

 

Sensation

-  decreased in C8 / T1 distribution

 

Power

-  decreased especially grip strength

 

1. Elevated Arm Stress Test (EAST)

- shoulder abducted 90° & ER 

- elbows at 90° 

- hands clasped / unclasped for 3min

- positive if symptoms reproduced or arms drop 2° pain & weakness

 

2.  Adson Manoeuvre

- head toward side tested, neck extended

- arm by side

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

3.  Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm abducted and ER

- breath in

- loss of pulse or reproduction of symptoms

- highly sensitive

 

Xray neck / CXR

 

Cervical rib

Clavicle fracture

 

CT 

 

MRI

 

May show fibrous band 

- exclude cord pathology

 

Angiogram

 

Must do with arms abducted and by side

- will show compression of subclavian vein

 

NCS

-  unhelpful as symptoms intermittent 

-  stimulus cannot be placed proximal to site of compression or irritation 

-  exclude CTS / cubital tunnel Syndrome

 

DDx

 

Cervical Disc (C8/T1) / spinal cord lesion

Ulna nerve entrapment

Shoulder pathology

Pancoast tumour

MS

 

Management

 

Non-operative

 

Explanation & reassurance

- shoulder girdle exercises 

- posture improvement 

- analgesia

 

Operative

 

 

Indications

 

10% of patients

- intolerable pain 

- significant loss of function

- significant arterial or venous symptoms

 

Options

 

Resection of cervical rib

Scalenectomy 

Resection first rib

Clavicular osteotomy

 

Complications

 

Chest

- pneumothorax 

- empyema 

 

Nerve injury 

- phrenic nerve 

- T1 

 

Vessel injury 

 

Recurrence of symptoms

 

 

Throwing Athlete

Throwing

 

Wind-up

- cocking

- ER up to 180o in pitcher

 

Acceleration

- large scapular muscles 

- acceleration - 7000o/sec

- rotatory acceleration similar to car tyre at 130 kph

 

Control and deceleration

- fragile cuff & glenohumeral ligament complex 

 

Anatomy

 

Pitchers have increased ER range, but corresponding decreased IR range

- have increased humeral head retroversion

- probably from adaptations of growth plate whilst young

- "little leaguer's shoulder" may be part of this

 

They have a "normal" abnormality

 

Treatment of posterior capsular stretching in athletes is debatable

- limited IR is normal state

 

Problems / Spectrum

 

1.  Subtle anterior instability / Posterior capsular contracture

- internal impingement

 

2.  SLAP

 

3.  Posterior instability

 

4.  RC injuries

 

Internal Impingement Posterior / Superior Glenoid

 

Definition

 

Described by Davidson 1997

- throwing athletes

- impingement in ER and abduction

- classic 90 / 90 position

- posterior aspect of SS impinges on posterosuperior rim of glenoid 

 

Pathology

 

Posterosuperior labrum is damaged

 

Cause

 

Argument whether posterior capsule tightness or anterior instability

- can be either

 

Symptoms

 

Usually posterior shoulder pain

 

Examination

 

Careful comparison of shoulders

- normal to have increased ER / decreased IR

 

EUA

- load and shift examination of instability very important

- need to examine shoulder in 90 / 90 position

- i.e. 90o ER and 90o abduction

- this is the throwing position

- look carefully for anterior instability

 

Diagnosis

 

Xray

 

Bennett's Lesion

 

MRI

- damaged posterosuperior labrum

- partial cuff tears

 

Arthroscopy

- place arthroscope anteriorly

- ER arm in 90o abducted position

- see posterior cuff impinge exactly on damaged area of labrum

 

Management

 

A.  Posterior capsule tight and thickened

- feel / confirm thickening with probe

- careful release at edge of labrum

 

B.  Shoulder unstable anteriorly in EUA

- may see anteroinferior labral injury

- may simple be redundant tissue

- anterior labral injury (careful repair with sutures)

- capsule stretched (advance part of capsule to glenoid rim to tighten)

 

NB Must be very careful

- cannot afford to lose ER in throwing athlete

 

Partial Thickness Tears Cuff

 

Pathology

 

Articular sided

- more posterior than in elderly

- at the SS / IS interval

- consistent with internal impingement

 

Associations

 

SLAP

Posterior capsular contracture

 

Aetiology

 

1.  Repetitive trauma from massive eccentric forces in SS and IS during deceleration in throwing

 

2.  Internal impingement from anterior subluxation / posterior tightness with posterior glenoid impingement and microtrauma

 

Non Operative

 

1.  ROM / posterior capsular stretches

- decrease inflammation

- NSAIDS

2.  Balanced RC exercises

 

Operative

 

Debridement is mainstay

- acromioplasty and repair rarely indicated

- some major league pitchers have full thickness tears

- repair initially may end career

 

Little Leaguer's Shoulder

 

Clinical

 

Present with painful shoulder

 

Xray

 

Physeal widening

 

Pathology

 

Chronic SH 1 growth plate

 

Management

 

Rest

 

 

 

 

Winged Scapula

 

Classification

 

Primary

 

Due to scapulothoracic articulation disorder

 

1.  Neurological Origin

 

A.  Spinal Accessory Nerve / Trapezius palsy

B.  Long Thoracic Nerve /  Serratus Anterior palsy

C.  Dorsal Scapular Nerve / Rhomboids palsy (rare)

 

2.  Osseous Origin

 

Osteochondromas (tangential x-rays, CT useful)

Fracture malunions

 

3.  Soft Tissue Origin

 

Muscular Origin

- traumatic ruptures of Serratus Anterior

- iatrogenic during thoracotomy

 

Secondary

 

Due to GHJ articulation disorders

A.  Erb's palsy

B.  Deltoid fibrosis

C.  Painful conditions i.e. RC tear, fracture, impingement

 

Voluntary

 

Rare

 

Trapezius Winging / Spinal Accessory Nerve

 

Anatomy

 

C3, 4

-  supplies Sternocleidomastoid

-  then runs in posterior triangle of neck to supply Trapezius (Upper 1/2)

 

Aetiology

 

Stab wounds to neck

Operations on posterior triangle (Lymph node biopsy)

Traction injuries

 

History

 

Pain

- will attempt to compensate by using levator scapulae

- can lead to disabling pain and spasm

- pain can also be from secondary effects (impingement / radiculopathy / Brachial plexus traction)

 

Examination

 

Shoulder depressed

- scapula translated lateral 

- inferior angles rotated laterally

 

Trapezius wasting

- unable to shrug shoulders

- weakness with protraction

 

Non operative management

 

Reasonable for a time for traction injury

- physio

- wait 6 - 12 weeks

 

Operative

 

1.  Neurorrhaphy

- direct repair for open laceration

 

2.  Nerve Graft

 

3.  Levator scapulae and Rhomboid transfer

- Eden-Lange procedure

- most common

 

Technique

- L. Scapulae to medial acromion

- R. minor upper 1/3

- R. major middle 1/3

 

4.  Scapulothoracic Fusion

- reasonable pain relief

- poor function

- high complication rate

 

Serratus Anterior winging / Long Thoracic Nerve

 

Anatomy

 

C 5, 6, 7 from Roots

- runs down posterior axillary wall

- deep to fascia

- posterior to midaxillary line

- supplies Serratus Anterior

 

Action

- boxer's muscle

- protracts scapula

 

Origin

- fleshy slips

- upper 8 or 9 ribs

 

Insert

- costal aspect medial margin

 

Aetiology

 

Surgery

- shoulder or neck operations

- 1st rib resection

- mastectomy

 

Carrying loads on shoulder

 

Trauma

 

Repetitive microtrauma - swimming

 

Examination

 

Winging of scapula

- scapula medial

 

Management

 

1.  Nerve Transfer 

- TDN to LTN

 

2.  Stabilisation of scapula / Marmor-Bechtol transfer

- transferring sternocostal head Pectoralis major to inferior corner scapula

- require fascia lata extension

 

 

 

 

 

Osteoarthritis

EpidemiologyShoulder OA

 

Usually 50-60 years old

 

Aetiology

 

1° uncommon

 

2° most common

- AVN

- trauma

- cuff arthropathy (Neer)

- instability

 

Pathology

 

Cuff & biceps intact as rule

- rare to have OA and rotator cuff pathology

 

Inferior osteophytes 

- beard

 

Retroversion of glenoid 

- posterior wear

 

Posterior subluxation not uncommon

 

Shoulder OA Posterior Subluxation

 

Tight anterior capsule & subscapularis

- limitation of ER

 

Post traumatic

- always soft tissue contracture

- limitation of ER

- CH ligament and rotator interval contracted

- malunion of tuberosities leads to impingement and offset of normal cuff action

- non-union results in extensive shortening of cuff

- scarring about axillary nerve

 

Signs

 

Global painful restriction of range of movement 

- due to incongruity of joint surfaces

- crepitus

- limitation of ER

 

DDx Limitation ER

 

Frozen Shoulder

Chronic posterior dislocation

Arthrodesis = Lack of ER

Post septic arthritis

 

X-ray

 

Shoulder OAShoulder OA Xray

 

Typical changes of OA

1. Teardrop osteophytes on inferior head & glenoid

2. Osteochondral loose bodies

 

Shoulder Loose Body

 

DDx

- cuff arthopathy - proximal migration of head & subacromial sclerosis

 

Arthroscopy

 

Shoulder OA GlenoidShoulder OA Debridement

 

Management

 

Non-operative

 

Education & Reassurance

- Analgesia

- NSAID

- Physio

ROM

Strengthening

 

Operative

 

1.  Arthroscopic Debridement

 

Concept

- if patient has acromial spur and acromioclavicular pathology

- may benefit from debridement

- concept of limited goals

 

Technique

 

A.  Glenohumeral joint

- deal with biceps tendon pathology if present (tenotomy / tenodesis)

- synovectomy

 

Shoulder OA Synovitis

 

B.  Subacromial space

- acromioplasty

- CA ligament left intact

- ACJ resection

 

C.  Removal beard osteophyte

- additional option

- may improve ROM

- risk of axillary nerve injury

 

2.  Arthrodesis

 

Indication

- may be considered in young active patient

 

Issues

- good pain relief but limitation movement

- difficult to perform

- rarely done in the modern age

 

3.  Excision Arthroplasty

 

Issue

- good pain relief but main problem is flail arm

 

4.  Arthroplasty

 

Options

- hemiarthroplasty (young patient or insufficient glenoid bone stock)

- TSR

 

 

Pectoralis Major Tears

Epidemiology

 

Middle age men

Steroids / Growth Hormone

 

Aetiology

 

Usually occurs in gym

Bench Press

 

Clinical

 

Significant bruising in the acute phase

 

In chronic setting, ask patient to adduct against hip / resistance

 

Pectoralis Major TearPectoralis Tear 2

 

Usually complain of weakness, mainly in gym

 

MRI

 

MRI Pectoralis Major TearPectoralis Tear MRI

 

Management

 

Non operative

 

Good results

Will have cosmetic deformity

Weakness usually only in the gym with bench press

 

Operative

 

Indications

- acute tears in young patients

- cosmesis i.e. body builders

 

Acute repair

 

Pect Major Repair Through Bone TroughIncision Pec Major Repair

 

Technique

- deltopectoral approach / can alos make in skin crease

- find tendons medially

- drill one inche trough in humerus

- place sutures in tendon

- pass sutures through drill holes lateral to trough

- pull tendon into trough and tie sutures

 

Chronic Reconstruction

 

Technique

- tendoachilles graft

- pass through muscle in pul ve taft method

- tie down into bone trough in humerus

 

Pect Major Reconstruction 1Pec Major Reconstruction 2Pec Major Reconstruction 3

Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture

 

>65

- third most common fracture after hip and distal radius

 

Anatomy

 

Neck shaft angle

- 130o

 

Head retroverted

- 20o relative to shaft

 

Anatomical neck

- junction of head and metaphysis

 

Surgical neck

- junction of diaphysis and metaphysis

 

Blood supply 

 

Gerber JBJS Am 1990 December

Anatomical cadaver study

 

1.  Anterior humeral circumflex

 

Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis

 

Nearly always disrupted in fractures

 

2.  Posterior Humeral circumflex

 

Small contribution posterior head

- allows head to survive with both tuberosities fractured

 

3.  RC

- supplies blood to tuberosities in fractures

 

Neer Classification 1970

 

Displaced 

-  any fragment > 1cm or > 45o

 

Number of displaced fragments

- 2 part (head/shaft, GT, LT)

- 3 part (head/shaft/GT, head/shaft/LT)

- 4 part (head/shaft/GT/LT)

 

Fracture / dislocation

 

Shoulder Fracture DislocationProximal Humerus Fracture DislocationShoulder Fracture Dislocation AnteriorPosterior Shoulder Fracture Dislocation

 

Head splitting fracture

 

SNOH Head Split CTProximal Humerus Head Split CT

 

Anatomical Neck Fracture

 

Humerus Anatomical Neck Fracture

 

AVN

 

SNOH AVN

 

In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- increases with amount of displacement

 

Rates AVN

 

4 part fracture 30%

 

3 part fracture 15%

 

Hertel Radiographic criteria

 

Hertel et al J Should Elbow Surg 2004

 

2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm

 

97% positive predictive of ischaemia if both factors present

 

Aetiology

 

FOOSH

- mostly elderly patients with osteoporotic

 

Young 

- high energy MVA

 

Deforming Forces

 

2 part fracture

- P. major displaces shaft medially

- head internally rotated by SSC

 

SNOH Fracture Displaced

 

GT fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor

 

Displaced Greater Tuberosity Fracture APDisplaced Greater Tuberosity Fracture LateralShoulder CT Displaced GT Fracture

 

LT fracture

- medially by SSC

 

Lesser Tuberosity FractureLesser Tuberosity Fracture 2

 

X-rays

 

AP / Scapula Lateral / Axillary lateral

 

CT 

 

Indication

- delineate no of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF / in elderly

 

Surgical Neck of Humerus CT 4 Part CoronalSurgical Neck of Humerus CT 4 Part SagittalSNOH CT 3 Parts

 

Associated Injuries

 

Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid

 

Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand

 

Management

 

Non operative 

 

Indications

- undisplaced

- elderly

 

NHx

 

85% are undisplaced and do not require surgery

 

Technique

 

Sling for 2/52 then mobilise

 

Results

 

Koval et al JBJS Am 1997

- 104 patients minimally displaced fracture as per Neer

- < 1cm displacement and <45o

- 90% no pain, 77% good or excellent result

- ROM approximately 90% of the other side

- 10% moderate pain and 10% poor result

- poor function and ROM associated with phyio started > 14 days after injury

- poor function associated with pre-existing cuff problems

 

Olerudet al JSES 2011

- RCT nonop v hemiarthroplasty for displaced 4 part

- 55 patients, average age 77

- 2 year follow up

- significant advantage of hemiarthroplasty

 

Operative Management

 

1.  2 Part Fractures

 

A.  SNOH

 

Indications

- >1 cm or > 45o

 

Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP

 

Options

- percutaneous wires / screws

- intra-osseous sutures

- proximal humeral nail

- locking plate

 

B.  GT 

 

Issues

- > 5mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step

 

Displaced Greater Tuberosity Fracture LateralCT Coronal Greater Tuberosity FractureCT GT Fracture Sagittal

 

Technique

- deltoid splitting approach

- young patient can ORIF with screw

- in elderly insert Mason Allen no 2 suture in cuff and tie over screw

- repair rotator cuff

 

 ORIF Greater Tuberosity FractureGreater tuberosity Tie over screw

 

Consequences Nonoperative Treatment

 

SNOH MalunionSNOH Malunion 2

 

C. LT Fractures

 

Soft tissue washer and screw

 

LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF

 

LT ORIFLT ORIF

 

2.  3 & 4 Part fractures

 

A.  ORIF with plate

 

SNOH Plate

 

Indications

- need sufficient bone quality

- always attempt in young

 

Results

 

Moonot et al JBJS Br 2007

- 32 patients with 3 or 4 part treated with Philos plate

- 31 of 32 united

- 27/32 (86%) excellent or satisfatory results

- 5/32 (16%) poor results

- 1 patient AVN and non union

 

Yang et al J Orthop Trauma 2010

- 64 patients treated with proximal humeral plate

- screw penetration into joint most common complication 5/64

- deep wound infection 2/64

- AVN 2/64

- 3 fixation failures requiring revision

- half good and half moderate shoulder scores, few excellent or poor

- all complications in 4 part fractures

- tuberosity malunion associated with poor outcome

 

B.  IM Nail

 

Results

 

Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions

 

C.  Hemiarthroplasty

 

Shoulder Trauma HemiarthroplastyShoulder Trauma Hemiarthroplasty

 

Indications

- unreconstructable

- elderly

- 4 part fractures

- head splitting fractures

- anatomical neck

- head impression > 40% articular surface

 

Proximal Humerus Unreconstructable

 

Problem

- only good ROM if tuberosities heal

 

Timing

- best to do in first three weeks

- whilst GT / LT still easy to mobilise

 

Results

 

ROM often poor

- better if anatomical union tuberosities

- early ROM gives better results (<2/52)

- rarely > 90o

 

SNOH Hemi 1SNOH Hemi 2

 

Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100o

- 16% moderate or severe pain

 

Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty

 

D.  Reverse total shoulder

 

Indication

- elderly patient

- poor cuff

- poor chance of tuberosity healing

 

Problems

- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding

 

Results

 

Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90o v 60o) and abduction (90o v 53o) better in reverse

- rotation better in hemiarthroplasty

 

ORIF Locking Plate

 

SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CT

 

Proximal Humerus 4 Part Head Splitting ORIF APProximal Humeral 4 Part Head Splitting ORIF Lateral

 

Technique

 

Set up

- GA, IV ABx, lazy beach chair

- mark anatomy

- II (patient either in middle of radiolucent table or remove lateral aspect shoulder table) 

 

Deltopectoral approach 

- cephalic usually taken lateral

- take part of pec major off to facilitate exposure

- Hawkins Bell retractor (shoulder charnley retractor) / non pointed double gelpies 

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractor deep to tendon

 

Dangers

- protect MCN under conjoint, minimal retraction

- find and protect the axillary nerve on inferior border of SSC, sweep finger inferiorly

 

Deep dissection

- clear sup deltoid bursa

- must elevate deltoid from head

- place a homan retractor over head to elevate deltoid

 

Identify structures

- remove callous

- reduce head onto shaft

- head is displaced posteriorly

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check for head splitting fractures

 

Find tuberosities

- secure with Mason Allen

- no 5 non absorbable

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check II now to avoid having plate too high

- must not leave head in varus

 

SNOH ORIF

 

Fixation

- to prevent cutout must have head out of varus

- long inferomedial screws / kickstand screws

- similar concepts to NOF (don't want screws high in the head)

 

Closure over drain

 

Rehab

- sling 6/52 with pendulars

- ROM 6/52

 

Complications

 

Non-union

- uncommon

- associated with AVN

 

 

 

Malunion

 

SNOH Malunion

 

Cutout

- medial support very important

- must avoid varus malreduction

 

Plate impingement

- need to ensure place plate low on the head

 

Screw perforation of humeral head

- most common complication

 

AVN

- fortunately uncommon

 

Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral

 

SNOH ORIF AVN

 

Vascular Injury

 

Axillary / MCN / Brachial Plexus

 

OA

- from signficant deformity

- TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy

 

Hemiarthroplasty

 

Proximal Humerus 4 Part Fracture In Elderly

 

Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2TSR Post OA

 

 

Technique

 

Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height

 

Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades

 

Deltopectoral approach

 

Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities

 

Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation

 

Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities

 

Need retroversion of 30o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30o

 

Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets

 

Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture

 

Place on head with 12/14 taper

 

Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole

 

Biceps tenodesis

 

Close over drain, rehab as above

 

Complications

 

Malunion / Non union tuberosities

 

Causes

- increased in women

- increased with initial malposition

- excessive height or retroversion of humeral head

 

Incidence

- 4-50%

 

Heterotropic ossification

- 10%

 

Glenoid degeneration

- 8% at 3 years

 

Prosthetic loosening

- 3-6%

 

Nerve injury

- AXN, MCN

 

Infection

- 1-2%

 

Stiffness

- need realistic goals

- aim to achieve function at shoulder height

Rheumatoid Arthritis

EpidemiologyRheumatoid Shoulder

 

Females

 

2/3 involved

- ACJ arthritis

- subacromial bursitis / rotator cuff pathology

- GHJ less commonly

 

Pathology

 

1.  ACJ 

- erosive arthritis

- joint expands with severe involvement

- ACJ capsular destruction / instability / impingement

 

2.  Subacromial Bursa

- becomes inflamed & thickened

- rupture of LH of biceps / cuff rupture

- rotator cuff arthropathy

 

3.  GHJ

- develop marked soft tissue inflammation

- 2° laxity capsule & folds of synovium

- followed by severe cartilage & bone erosion

 

Neer described 3 types RA shoulder

- Wet = Synovitic with soft tissue pathology

- Dry = Articular Surface Erosion

- Resorptive = Severe Bony Erosion

 

History

 

Shoulder pain & swelling with flares of RA

- gradually decreasing ROM

- functional impairment

 

Cuff Tendonosis 

- pain with overhead activity

 

Examination

 

Deformity 

- muscle wasting

- humeral medialisation 2° bone loss in glenoid cavity with humeral protrusion

- effusion with swelling

 

Cuff rupture 

- loss of abduction

 

Biceps rupture / popeye

 

Painful arc

 

Xray

 

Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions

 

Rheumatoid Shoulder Erosions

 

Symmetric Arthritis

 

Protrusio

- medialisation of humeral head

- can erode anteriorly or posterior

- inferior glenoid preserved

 

Rheumatoid Shoulder 2

 

Superior migration due to cuff rupture

 

Arthritis mutilans

 

Arthritis Mutilans RA

 

US / MRI / Arthrogram

 

30% have cuff tear

 

Rheumatoid Shoulder Arthrogram Cuff Tear

 

CT

 

Assess glenoid stock

 

Rheumatoid Shoulder CT

 

Aspiration

 

RA

- 20 000 WBC / ml

- 60-70% neutrophils

 

Sepsis

- > 100 000 WBC / ml

- > 75% neutrophils

 

DDx

 

Septic arthritis

 

Gout

- sodium urate

 

Pseudogout

- calcium pyrophosphate

 

Milwaukee Shoulder

- calcium hydroxyapatite crystals

 

RC arthropathy

 

OA - beard osteophytes

 

Management

 

General

- Medical treatment

- HCLA injections

 

ACJ

 

Excision of outer 1/3 of clavicle

 

Subacromial Bursa

 

SAD

Bursectomy

 

GHJ

 

1.  Arthroscopic Synovectomy 

 

Indications

- mild arthritis / cuff intact

 

Technique

- synovectomy

- via anterior and posterior portals

- removal loose bodies

- biceps tenotomy

- bursectomy / ACJ resection if necessary

- minimal acromioplasty especially if cuff tear as must preserve CA ligament

 

Rheumatoid Shoulder Arthroscopy Rheumatoid Shoulder Post Debridement

 

Rheumatoid Shoulder Arthroscopy 2Rheumatoid Shoulder Arthroscopy 3

 

Cofield et al Arthroscopy 2006

- 16 shoulders followed up for 5 years

- 13/16 good pain relief

- some mild improvement in ROM

- arthritis tended to progress over time

 

2.  Hemiarthroplasty / TSR

 

Indications hemiarthroplasty

- young patient

- glenoid not involved / unusual

 

Indications TSR

- sufficient bone stock glenoid

- glenoid often deficient centrally and superior

- intact RC
 

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR

 

4.  Reverse TSR

 

Indications

- ruptured cuff (30%)

 

Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects

 

5.  Arthrodesis

- indicated for severe bone loss

- problem is actual or potential involvement of other joints

 

6.  Excision arthroplasty

- salvage procedure

Rotator Cuff

Calcific Tendonitis

Definition

 

Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia

 

Supraspinatous CalciumSupaspinatous Large Deposits

 

Aetiology

 

2 groups of patients

 

1.  Degenerate Calcification

 

Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller

 

These patients do not have calcific tendonitis

- older patient group

- different histology

 

2.  Calcific Tendonitis

 

Cause

 

Reactive Hypoxic Calcification Theory

 

Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium

 

Codman proposed cuff hypoxia as the causative factor

 

Classification

 

1.  Pre-Calcific stage

 

Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia

 

2. Calcific Stage

 

A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

- crystals may be in the form of phosphates / carbonates / oxalates / hydroxyapatite

 

B. Resting Stage

- fibrocartilage surrounds deposits

 

C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma

 

3. Post-Calcific Stage

 

Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I

 

Epidemiology

 

Accounts for 10% all consultations for painful shoulder

 

Peak 40 years

- diabetes

- F > M 

 

SS most common tendon

- IS less common

- SSC rare

 

Asymptomatic patients can have cuff calcium on xray

 

Clinical Presentation

 

Usually acute pain

- Resorption Stage

- background of absent to mild chronic pain of the Formative Stage

 

Patients may present to ED

- severe pain

 

DDx infection

 

DDx

 

Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD

IHD

 

X-ray

 

Calcific Tendonitis APCalcific Tendonits Lateral

 

Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size

 

ER AP Xray

- shows SSC

 

Subscapularis CalciumSubscapularis Calcium Lateral

 

IR AP Xray

- shows IS & Tm

 

Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak

 

Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density

 

MRI 

 

Low signal on T1 

Oedema on T2

 

Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2

 

US 

- more sensitive than Xray ~100%

 

Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous

 

Bloods

 

Check serum glucose / uric acid & iron

 

Management

 

Non operative Management

 

Options

 

1.  NSAIDS

- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration

 

Extracorporeal shock wave therapy

 

Extracorporeal Shock Wave Machine

 

Peters Skeletal Radiol 2004

- RCT

- 90 patients

- treatment group complete resolution in 86%, reduction in size in 13.4%

- control group 0 disappeared completely, 9% partial reduction

- significant reduction in pain and improvement in function at 4 weeks

- no adverse affects

 

Effectiveness directly related to energy

- 0.44 mJ/mm3

 

Needle aspiration and irrigation

 

Aim

- drain a substantial portion of the calcium

- stimulate resorption of remainder

 

Indications

- resorption phase (soft, toothpaste material)

 

Contraindications

- small deposits

- formative phase (hard, chalky material)

 

Technique

- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive

 

Complications

- very painful for first 2-3 days

 

Results

 

Aina et al Radiology 2001

- excellent results in 74%

 

Serafini et al Radiology 2009

- non randomised controlled trial

- patients treated better at 1 month / 3 months and 1 year

- no difference long term

 

Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone

 

Operative Management

 

Indications

- severe disabling symptoms > 6 months

- failure of needling / ECSW

 

Issues

 

Acromioplasty

- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement

 

Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

- SAD much longer time to return to non painful shoulder activity

 

Options

 

Open

Arthroscopic and mini open

Arthroscopic

 

Arthroscopic Technique

 

Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit

 

Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon

 

Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness

 

May need to remove entire diseased section and repair

 

Calcific Tendonitis Arthroscopy 1Calcific Tendonitis Arthroscopy 2Calcific Tendonitis Arthroscopy 3Calcific Tendonitis Arthroscopy 4

 

Complications

 

Secondary stiffness

 

Pain

- secondary to calcium deposits

- careful shoulder washout at the end of the case

 

 

Cuff Tear Arthropathy

DefinitionRotator Cuff Arthropathy

 

Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch

 

History

 

Neer

- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases

 

Aetiology

 

Crystal induced arthropathy

- hydroxyapatite-mineral phase in altered capsule, synovium or degenerate articular cartilage

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally

 

Cuff tear theory

- loss of cuff leads to mechanical and nutritional alterations in shoulder

- due to loss of closed joint space and altered range of motion

 

Incidence

 

4% of massive cuff tears go on to arthroplasty

 

Theory

- tears with unbalanced force couplet go on to arthropathy 

- massive tear that are balanced & / or above equator don't go onto to arthropathy

 

Epidemiology

 

Women > men

60% bilateral

 

Symptoms

 

Recurrent swelling

Loss of Motion

Night pain

 

Xray

 

1.  Superior migration of head 

- defined as AHI / acromiohumeral interval of 7mm or less

 

Humeral Head Superior Migration

 

2.  Collapse of proximal head articular surface 

 

3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity

 

4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification

 

Acromial Acetabularisation

 

CT

 

RC Arthropathy CT

 

DDx

 

GH OA 

- no superior migration

- beard osteophytes

 

Management

 

Non-Operative

 

Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia

 

Operative Management

 

1.  Acromioplasty & tendon debridement 

 

Not indicated with superior migration

- can consider biceps tenotomy if still intact

 

2.  Arthrodesis

 

Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid

 

3.  TSR 

 

Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 

 

4.  Hemiarthroplasty

 

Indications

- < 70

- intact CA arch

- anterior deltoid muscle

 

Technique

- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape

 

Results

 

Rockwood

- 18 of 21 satisfactory

- good pain relief

- ROM often not improved

 

Neer 

- concept of limited goals category

- 20° of ER and 90° of forward elevation

 

Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency

 

5.  CTA Humeral Head

 

Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER

 

CTA HemiarthroplastyCTA Head APCTA Head 2

 

6.  Reverse TSR

 

Indications

- > 70

- functioning deltoid

 

Concept

- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder

 

 

 

 

Impingement

Arthroscopic Acromioplasty

Technique

 

Position

- beach chair / lateral

- water pump, adrenaline in bags

- block pre-op useful as easier to control BP

- often inject the SAD with combination of LA with A prior to scope

 

Posterior portal

- 2 cm inferior, 1 cm medial

- soft spot between IS and Tm

 

Enter subacromial space

- sweep to clear adhesion

- saline on pump at 30 - 40 - 50

- keep BP  100 - 110

- can increase pump pressure to 60 - 80 if needed in short bursts

 

Midlateral portal

- spinal needle

- 3cm distal to anterior acromion

- midpoint clavicle

- slightly lower to aim up

 

Bursectomy

- with shaver

 

Arthroscopic Bursectomy

 

Electrocautery / Shaver

- clear periosteum / coracoacomial Ligament off acromion

- avoid deltoid as bleeders

- beware thoroaco-acromial artery in CA ligament medial and inferior to acromion

- spinal needle ACJ to mark medial limits

- need to see anterior and lateral acromion

 

Arthroscopy Type 3 AcromionShoulder Scope Large Acromial Spur

 

Acromioplasty

- 5.5mm burr

- multiple techiques

- 5mm deep resection at midpoint clavicle

- taper anteriorly

- must ensure lateral edge is cleared

 

Arthroscopy Post AcromioplastyArthroscopy Cleared Subacromial Space

 

Residual Lateral Acromial Spur

 

 

 

 

Impingement

DefinitionLateral Acromial Spur

 

Painful impingement of rotator cuff

- on anterior 1/3 of Acromion, CA ligament & ACJ

- causes tendinosis of the RC

 

Anatomy Subacromial Space

 

1.  Roof / CA Arch

- acromion

- CA ligament

- coracoid process

- ACJ is superior & posterior to CA ligament

 

2.  Floor 

- GT & superior aspect head

- rotator cuff

 

Aetiology

 

Controversial

- extrinsic and intrinsic theories

 

1.  Extrinsic / Extra-tendinous / Bursal sided tears

 

CA arch impinges on RC

- true impingement syndrome

- causes tendinosis of the cuff

 

Factors

 

A.  Subtle GH Instability

- relationship poorly understood

- respond poorly to acromioplasty

- alteration in dynamics of shoulder

 

B.  Internal Impingement Posterior / Superior Glenoid

 

Described by Davidson 1997

- throwing athletes

- impinge in abduction & ER

- SS impinges on posterosuperior rim of glenoid 

- normally humeral head translates posterior in glenoid 

- this may be lost with instability or laxity of throwing athlete

- alternatively may be caused by posterior capsular tightness

 

See Miscellaneous/Throwing Athlete

 

C. Degeneration ACJ

 

OA Spurs

 

D.  Acromion Morphology

 

Neer = impingement on anteroinferior acromion 

 

E.  Os Acromiale

- mesoacromion most common

- hypermobile unfused epiphysis

- tilts anteriorly

- 1-15% normal population

- increased incidence with impingement

 

F.  CA Ligament Spurs 

 

Develop calcium in tendon

 

G.  CA Ligament Impingement

- common

- "Snapping shoulder"

- in flexion & IR

- SS & Biceps impinge on it

- Neer recommends division

 

H.  Coracoid Impingement

- less common

- subscapularis impingement between coracoid and LT

- may be exacerbated by anterior instability

- more medial pain with arm flexed, adducted and IR

- find SSC partial tears on arthroscopy

 

Coracoid Impingement Lateral Coracoid

 

2.  Intrinsic / Intra-tendinous / Articular sided tears

 

2° to bursal thickening or intrinsic problem in cuff

- ? Now thought to be most common

 

Factors

 

1. Muscle Fatigue

- overloaded weak muscles

- eccentric tension load

- associated with proximal humeral migration

 

2. Shoulder Overuse

- soft tissue inflammation

- repetitive microtrauma

- athletes / manual labourers

 

3. Degenerative Tendinopathy

- 1° intrinsic degeneration of RC

- ? hypovascularity

- increasing incidence with age

 

Pathology

 

Impingement Zone 

- centered on supraspinatus tendon insertion

- Codman's "Critical Zone" 1cm from insertion

- zone of hypoperfusion

 

Neer's Pathological Classification

 

Stage I

- reversible

- oedema & haemorrhage

- < 25 years

 

Stage II

- irreversible change

- fibrosis & tendinitis

- 25-40 years

 

Subdivided by Gartsman

- Stage IIA = No tear

- Stage IIB = Partial thickness tears

 

Stage III

- > 40 years

- chronic

- partial & full thickness tears

 

Acromial Morphology

 

Bigliani / Assess on Supraspinatous Outlet View / Scapula Lateral

 

Type I:  Flat

- 20% of normal population

 

Type 1 AcromionType 1 Acromion

 

Type II:  Curved

- 40% of normal population

 

Type 2 Acromion

 

Type III:  Hooked

- 40% of normal population

- 80% of RC tears

 

Type 3 AcromionAcromion Type 3Acromial Spur Type 3

 

Cadaver study

- 30% of all cadavers had a full thickness cuff tear

- 75% type III & 25% type II & 3% type I

 

Morphology does change with age

- Spur more common > 50 years

- ? 2° event to cuff process

- most hooks appear to be acquired & lie in CA ligament 

 

Symptoms

 

Painful arc

 

Weakness overhead

 

If < 40 years look for instability

 

Examination

 

Painful Arc

- 70-120°

- > 120° - ACJ OA / terminal phase pain

 

IR

- limitation of IR may suggest posterior capsular tightness

 

Neer Impingement Sign

- stabilize scapula from behind patient

- passively elevate arm in scapula plane

- pain between 70-120°

 

Hawkins Modification

- IR humerus at 90° flex

 

Neer Impingement Test 

- LA in SAD

- abolish pain & test for cuff tear / weakness

 

Always

- anterior apprehension / Jobes relocation (young patient)

- ACJ assessment

- biceps assessment

- NVI

- C spine

 

X-ray

 

AP view (True AP)

- acromio-humeral interval:  Normal 1-1.5 cm, < 0.7cm abnormal

- sclerosis greater tuberosity / acromion

- lateral Acromion spur

- OA ACJ

 

Acromial Spur AP

 

Axillary Lateral

- os acromion

- bone scan to exclude symptomatic hypermobility

 

Os Acomionale Axillary Lateral Xray

 

Supraspinatus Outlet View

- Acromion morphology / calcification Coraco-Acromial Ligament

- scapula lateral variant

- plate on affected shoulder, other turned out of way 

- 10° caudal

 

Scapular Lateral for Acromial Morphology

 

Zanca view

- ACJ

- half voltage / centred on ACJ / 10o cephalad

 

US

 

Diagnose

- dynamic impingement

- bursitis

 

Shoulder Ultrasound Bursitis

 

MRI

 

Sensitive

- assess acromial morphology

- look for tendinosis / tears

 

MRI Type 3 Acromion

 

Management

 

Non Operative

 

HCLA injection 

 

Goals

- decreases pain & inflammation

- diagnostic

 

Alvarez et al Am J Sports Med 2005

- RCT HCLA v LA in RC tendonosis

- no clinical difference between the two groups

 

Cuff Rehabilitation

 

Rockwood 3 Stages of Physio

 

1. Decrease Inflammation / Increase ROM

- rest

- gentle ROM 

- posterior capsular stretches

- scapula & trunk stabilisers

- modify activities

- NSAIDS

 

2. Cuff Stabilisation and Balancing

- strengthen humeral depressors

- work on SSC and IS

- takes load off SS

- theraband / IR / ER exercises

- avoid abduction drills

 

3. Deltoid strengthening

- task specific exercises

 

Operative Management

 

Acromioplasty

 

Theory

 

Believe primary problem is extrinsic impingement

- abnormal acromial morphology on outlet view

- spurs in CA ligament

 

Results

 

Ketola et al JBJS Br 2009

- RCT of patients with impingement

- treated with exercise program or acromioplasty + exercise program

- no difference between the two groups

 

Henkus et al JBJS Br 2009

- RCT of bursectomy alone v bursectomy + acromioplasty

- no difference between the two groups

 

Open v Arthroscopic Acromioplasty

 

Results

 

Sachhs JBJS 1997

- open v arthroscopic

- open longer return to work & in hospital stay

- results similar

 

Davis et al Am J Sports Med 2010

- meta-analysis of open v arthroscopic acromioplasty

- no significant difference in outcome

- longer return to work and inpatient stays

Open Acromioplasty

Described by Neer / modified by Rockwood

 

Two Step Acromioplasty

 

1.  Anterior acromioplasty

- resect anterior acromion back to ACJ

- prevent impingement in flexion

 

2.  Resect anteroinferior acromion 

 

Technique

 

Position

- beach chair 

- mark anatomy

- limb draped free

 

Incision 

- along anterolateral border acromion

- curve into anterolateral incision

 

Superficial Dissection 

- expose deltoid to ACJ

- find fibrous raphe at anterolateral corner acromion 

- marks anterior & middle parts of deltoid

- split raphe 3cm, ensure protect underlying cuff

- bursa is now exposed, separate subdeltoid space

 

Deep Dissection

- detach deltoid from anterior acromion to ACJ 

- release CA ligament 

- place retractor under acromion to protect cuff

- tablespoon, Langerhan's retractor turned on side

 

2 stage acromion resection with microsagittal saw

- anterior acromion level with ACJ

- antero-inferior acromion

- ensure surface smooth

 

Resect distal 2cm clavicle if OA

- < 4% of patients

- only if pain referable to ACJ 

- confirmed by LA preoperatively

 

Bursectomy

- inspect cuff & repair defects

- abduct & rotate humerus

- biceps tenodesis if > 50% torn

 

Closure

- ? repair CA ligament

- reattach Deltoid No. 2 ethibond intraosseous sutures

 

Post Op

- rendulum exercises & passive flex

- sling for comfort

- no active abduction for 6/52 to protect deltoid

 

 

 

RC Tears

Arthoscopic Supraspinatous Repair

 

Large Supraspinatous TearSS tear arthroscopy GHJSS tear arthroscopy

 

Advantages

 

Improved cosmesis

Shorter hospital stay / less immediate post operative pain

Deltoid not detached

Ability to evaluate and treat coexisting intra-articular pathology i.e. biceps

 

Disadvantage

 

No quicker to rehab or return to activities 

- limiting factor is healing of tendon to bone

- healing rates not as high especially for large to massive tears

- steep learning curve / longer surgery

 

Issues

 

1.  Footprint

- 25 x 15 mm

- healing zone

- the greater the extent a repair covers, the greater the chance for tendon bone healing

 

2.  Suture technique

 

Note:  Most common means of failure is suture cutout

 

A.  Open transosseous

 

Technique

- performed in open surgery

- captures a wide section of cuff footpring

- very secure repair with uniform compression between cuff and bone

 

B.  Single row repair

 

Technique

- anchors placed in line laterally at insertion

 

C.  Double row repair

 

Technique

- medial anchor row at articular margin

- lateral anchor row at lateral footprint

 

Kim et al Am J Sports Med 2006

- biomechanical study

- more successful at restoring footprint

- less gap formation

- increased load to failure

 

D.  Transosseous equivalent / suture bridge

 

Technique

- biomechanically replicate tradional open transosseous

- sutures crossed as below in double row

- aiming to increase contact between cuff and footprint

 

Arthroscopic Suture Bridge Cuff Repair

 

Siskoksy et al AAOS 2007

- biomechanical study suture bridge v double row

- bridge higher load to failure

- no difference in gap formation

 

Results 

 

Outcome arthroscopic

 

Lafosse et al AA Should Elbow Surgeons 2006

- 105 patients treated with double row

- 11.45 structural failure on CT / MRI

 

Sugaya et al JBJS Am 2007

- prospective study 106 FT

- arthroscopic double row

- MRI follow up

- 17% retear

- 5 % small to medium

- 40% large and massive

 

Arthrocopy v mini-open

 

Kim et al Arthroscopy 2003

- arthroscopy v mini open

- similar outcomes in each group

- poor outcome related to size of tear, not method of repair

 

Verma et al Arthroscopy 2006

- arthroscopy v mini open

- US review

- 24% retear mini-open

- 25% retear arthroscopic

- no difference in outcome

 

Bishop et al AAOS 2004

- mini open v arthroscopic

- MRI review

- tears < 3 cm: 26% retear mini open, 16% arthroscopic

- tears > 3m: 38% v 76%

- do larger tears do better with open surgery?

 

Morse et al Am J Sports Med 2008

- meta-analysis of arthroscopic v open

- no difference in outcome or complications

 

Single v Double Row

 

Francheschi et al Am J Sports Med 2007

- RCT single v double row

- 60 patient

- no difference functional outcome

- improved cuff appearance on MRI

 

Burks et al Am J Sports Med 2009

- RCT single row v double row

- 20 in each group

- 1 retear in each group

- no difference in MRI appearance or clinical outcome

 

Cost

 

Churchill et al J Should Elbow Surg

- arthroscopic took average 10 minutes longer / cost $1000 dollars more

- even at high volume centres

 

Arthroscopic Supraspinatous Repair

 

Technique

 

Position

- lateral decubitus with arm traction 10 lb or

- beachchair in Tmax / Spyder (can depress arm and ER to aid visualisation)

- water pump

- useful to have adrenalin in bags

- stable BP 110 (interscalene block can help)

- inject LA with A into subacromial space and prospective portals

 

Portals

 

Posterior Portal

- make more superior and lateral

- awkward for GHJ arthroscopy

- good visualisation in subacromial space

- will put camera over and high above tear

 

Lateral portal

- standard position

- insert large 8 mm cannula (will need to pass sutures)

- perform bursectomy +++ for visulisation

- bursa posteriorly and medially often bleeds

- perform SAD

- control bleeding with electrocautery and temporary increases in pump pressure

 

Anterior portal

- smaller 6 mm

- for suture shuttling

 

Preparation

 

Prepare insertion

- debride tendon edges

- debride footprint to punctate bleeding

 

Arthroscopic Cuff TearArthroscopic Cuff Prepare InsertionArthroscopic Cuff Prepared Footprint

 

Assess tendon mobilisation / tear geometry

- perform releases if needed

- as per open surgery

- above and below tendon 1 cm medial to glenoid

- release coracohumeral ligament

 

Repair

 

Large U shaped tendon

- insert margin convergence sutures

- put camera in lateral portal

- insert posterior cannula over switching stick

- anterior and posterior bird beaks

 

Arthroscopic Cuff Repair Margin Convergance 1Arthroscopic Cuff Repair Margin Convergance 2

 

Place medial row anchors

- anterior first

- insert 18 G spinal needle and ensure good angle

- just medial to articular cartilage

- stab incision

- insert 5 mm anchor

 

RCR arthroscopic Spinal NeedleRCR Arthroscopic TapRCR Arthroscopic AnchorRCR Arthroscopic Anchor 2

 

Pass sutures in lateral margin cuff

- camera posterior

- elite / scorpion / concept suture passer via lateral portal

- pass sutures through cuff anterior to posterior

- retrieve sutures through anterior portal

- retrieve via anterior portal

 

Suture PassageSuture Retrieval

 

Repeat with posterior anchors

 

Large Cuff Repair 1Large Cuff Repair 2Large Cuff Repair 3

 

Tie sutures

- posterior to anterior / anterior to posterior

 

Double row

- either pass second lateral row of anchors or

- use foot print anchors, retrieve previous sutures

- can make suture bridge configuration

- check repair via lateral portal

 

Arthroscopic Supraspinatous RepairArthroscopic Cuff Suture Bridge RepairArthrscopic Cuff Repair

 

 

Background

Definition

 

Full thickness tear (FTT)

- variable amount retraction from insertion

 

Rotator Cuff Tear Large

 

Partial thickness tear (PTT)

- incomplete

- bursal or articular sided

 

Articular sided tearBursal Tear

 

Epidemiology

 

Older patients

- average age 60

- uncommon < 40

- cadavers  30%

 

Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years

 

Anatomy

 

Blood Supply

 

Proximal from muscle belly

- suprascapular artery

- subscapular artery

 

Distal from bone

- branch of anterior circumflex humeral

 

Vessels more abundant on bursal side than articular side

 

NHx

 

1.  Healing

- full thickness tears don't heal because of presence of synovial fluid

 

2.  Progression

- tears do not necessarily extend

 

3.  OA

- 5% FTT go on to cuff arthropathy if untreated

 

Pathogenesis

 

Chronic Tears

- 95% 

- abnormal tendon

 

Acute tears

- trauma 

- 5% 

- normal tendon

 

Pathology

 

No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia

 

Involvement

- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn

 

Classification

 

1.  Size 

 

Cofield

- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm

 

2.  Extent

 

Partial Thickness

 

Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium

 

A.  Intra-tendinous

- in tendon

- no communication with bursa / joint

 

Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis

 

B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly

 

Supraspinatous articular sided tear

 

C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement

 

Full Thickness

 

One tendon 

- supraspinatus only

 

Multiple Tendons 

- more likely OA if multiple tendons involved

 

3.  Topography

 

Sagittal Plane

 

Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons

 

Coronal Plane

 

A. Minimal retraction

- close to insertion

 

Supraspinatous Tear Minimal Retraction

 

B. Moderate retraction

- humeral head

 

Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2

 

C.  Significant retraction

- at glenoid

 

Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1

 

History

 

Pain

 

Weakness

- 2° to tear

- can be limited by pain

- can use LA to differentiate

 

History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon

 

Chronic Tear 95%

-  long history impingement

-  no history of injury

 

Examination

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Wasting

- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears

 

Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear

 

Supraspinatus

 

1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate

 

2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o

 

3.  Shoulder hiking

- usually means massive cuff tear

 

Shoulder Hiking

 

Infraspinatus

 

1.  Resisted ER

 

2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags

 

3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor

 

Involvement of IS can often indicate a large or massive tear

 

Subscapularis

 

1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test

 

2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly

 

3. Increased ER compared with other arm

 

Subscapularis tear increased ER

 

HCLA

 

Improves pain and allows physio

 

Diagnostic

- ensures pain from shoulder pathology

 

Xray

 

Views as for impingement

- assess acromion / GHJ OA / high riding head

 

Ultrasound

 

Advantages

- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery

 

Disadvantage

- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)

 

Evidence

 

O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable

 

Normal

 

Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal

 

Tears

 

Shoulder Ultrasound Supraspinatous Tear

 

Arthrogram

 

Arthrogram Intact RC

 

MRI

 

Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 

 

Shoulder MRI Supraspinatous Fatty Infiltration

 

Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space

 

For more MRI see

- massive tears

- partial thickness tears

- full thickness tear

 

Arthroscopy

 

Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space

 

Management Guidelines

 

1. Repair all acute full thickness tears

 

2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain

 

3. Observe chronic tears with no disability

- especially in elderly

 

Non-operative Management

 

As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears

 

 

 

Full Thickness Tears

Surgical Options

 

1.  Open antero-lateral approach 

 

Large / Massive Cuff Tear

 

2.  Deltopectoral approach

 

Large Subscapularis tear

 

3.  Arthroscopic Assisted Mini-open

 

Indication

- Small / Moderate Cuff Tear < 3cm

- no retraction

 

Technique

- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split

 

Advantage

- avoids deltoid detachment from acromion

- small scar

- still have to immobilise shoulder for 6/52 to protect cuff tear

 

4.  Arthroscopic repair

 

SAD

 

Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not

 

Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs

 

Biceps / SLAP

 

Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group

 

Morphology

 

4 types of cuff tears

 

1.  Cresent shaped

- simple lateral repair

 

Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped

 

2.  U shaped

- larger

- need margin convergence, then lateral repair

 

Supraspinatous Tear U shaped

 

3.  L shaped

 

Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly

 

4.  Massive

 

Rotator cuff retracted to glenoid

 

1.  Open Rotator Cuff Repair

 

Indications

- large to massive tear

 

Concept

- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures

 

Advantage

- reliable

- good results in terms of tendon healing and outcome

 

Disadvantage

- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

- miss any intra-articular pathology if don't perform arthroscopy

- ? management of biceps

 

Technique

 

Position

- lazy beachchair

 

Incision

- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid

 

Approach

- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

- must not extend incision > 5 cm from acromion or risk damaging anterior AXN

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery

 

Acromioplasty

- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure

 

Bursectomy

 

Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint

 

Techiques to mobiise retracted SS tendon

 

1.  Release CHL (runs from coracoid to free edge SS / into rotator interval)

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

4.  Release above glenoid 1.5cm (beware suprascapular nerve)

5.  Interval slide - divide between SS and IS posteriorly, rotator interval anteriorly

6.  Medialise insertion - take away some of articular cartilage

7.  Repair SSC and IS for restoration of force couplet (if SS irrepairable)

 

Repair Options

 

1.  Direct suture of tendon

- margin convergence

 

2.  Suture of tendon to bone

 

A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across

 

Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral

 

B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors

 

C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)

 

3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head

 

Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow

 

Closure

- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery

 

Large - Massive Tear 

 

Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above

 

Post op

 

Must protect deltoid repair

- passive ROM 6/52, hand and elbow exercises, sling

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12

 

Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM

 

2.  Arthroscopic SAD + Mini open Rotator Cuff Repair

 

Concept

- perform subacromial decompression with arthroscope

- no need to detach deltoid

- made 2 - 5 cm deltoid split directly over tear and repair

 

Indication

- moderate size tear up to 3 cm

 

Technique

- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above

 

Results

 

Open v Mini-open

 

Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years

 

Tear integrity

 

Papadopolous et al J Should Elbow Surg 2011

- ultrasound evaluation of tears at 3 years in 37 mini-open patients

- 48% intact in patients who tended to have smaller original tears and be 15 years younger

- most patients had satisfactory outcome

 

Complications

 

Rerupture

- up to 50%

- increased in older patients with larger tears

 

Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head

 

Shoulder High RIding Humersu

 

Infection

 

Pain

- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)

 

Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture

 

Stiffness

 

Deltoid avulsion

 

Axillary nerve injury

 

Acromial fracture

 

RC Tear / Anchor Pullout

 

Rotator Cuff Anchor Pull Out

 

Massive Tears

DefinitionsMassive RC Tear High Riding Humeral Head MRI

 

Massive tear 

 

1.  > 5cm 

- retracted to humerus / glenoid margin

 

2.  At least 2 complete tendons

- lose SS / IS or SS / SC

 

Classification

 

Antero-Superior

- SS + SSC

 

Postero-Superior defects

- SS + IS
- more common

 

Pathogenesis

 

Cuff works to compress / depress head in glenoid while deltoid acts as prime mover

- ff still have intact force couple often good function

 

Plan is to reproduce force couple 

- if tear is below equator of head 

- get uncoupling of cuff force couple

- lose cuff depressor effect & acts as head elevator

 

Integrity of coracoacromial arch integral component of repair

- acts as check rein to proximal migration 

 

Presentation

 

Massive SS / IS wasting + rupture LHB

- weakness

- reduced active ROM

- atrophy

 

Shoulder Hiking due to massive cuff tearSupraspinatous and Infraspinatous wasting

 

2 classic signs

 

1.  ER lag sign

 

2.  Hornblowers

- 100% sensitive, 93% specific

 

Both indicate infraspinatous is torn which is usually a sign of a massive PS tear

 

DDx

 

Suprascapular nerve palsy

Brachial plexus injury

Cervical stenosis

 

X-ray

 

Reduced acromiohumeral space

- < 7 mm RC tear

- < 5 mm massive tear

 

Rotator cuff OA

- acetabularisation

 

Decreased Acromioclavicular DistanceShoulder Massive Rotator Cuff Tear CTMassive Rotator Cuff Tear

 

MRI

 

1.  Level of retraction

- past coracoid irreparable

 

MRI Supraspinatous Retracted to Glenoid Margin

 

2.  Quantify fatty infiltration Goutallier

 

Parasagittal MRI T1

- atrophy and fatty replacement in SS / IS fossa

 

0 - no fat

1 - minimal fat

2 - more muscle than fat

 

Supraspinatous fatty infiltration grade 2

 

3 - fat equal muscle

 

MRI Fatty Infiltration Supraspinatous Infraspinatous

 

4 - more fat than muscle

 

Grade 4 Fatty Atrophy

 

3 & 4 have poor prognosis

- poor functional improvement with repair

- high incidence of retear

 

3.  Atrophy

 

Also poor prognosis

 

MRI Supraspinatous Atrophy

 

Management

 

Non Operative

 

Physio /  HCLA

- improvement in 50-85%

 

Operative

 

Options

 

A.  Primary repair / Debridement

1.  Mobilisation and repair

2.  Partial repair

3.  Decompression and debride

4.  Suprascapular nerve release

 

B.  Salvage

1.  Local tendon transfer - SSC

2.  Distant tendon transfer - P. major / Lat dorsi

3.  Allograft

4.  Synthetic Graft

5.  Arthroplasty

 

Repair / Debridement

 

1.  Rotator Cuff Mobilisation and repair

 

Technique of mobilisation

- release coracohumeral ligament

- anterior slide (between SS and SSC)

- posterior slide (between SS and IS)

- release above glenoid 1 cm

- medialise insertion

- transosseous repair

 

Results

 

Bigliani et al J Should Elbow Surg 1992

- 61 patients massive cuff tears followed up 7 years

- open repair

- 50% excellent and 30% good

 

2.  Partial repair

 

Theory

- restore balanced force couplet

- SSC + partial SS / IS repair

- act in conjuction to depress humeral head

- allow deltoid to work

 

Massive Cuff TearMassive Cuff Tear Partial Repair 1Massive Cuff Tear Partial Repair 2

 

Massive Cuff Repair Partial Repair 3Massive Cuff Tear Partial Repair 4Massive Cuff Tear Partial Repair 5

 

Results

 

Rhee et al Am J Sports Med 2008

- partial repair with interposition of biceps tendon to bridge gap

- MRI of 14 / 16 cases done arthroscopically

- complete healing in 60%

 

3. Decompress & debride alone

 

Concept

- doesn't restore power

- aiming for pain relief in elderly population

 

Technique

- maintain Coracoacromial arch to prevent humeral head escape

- don't perfrom SAD to preserve CA ligament

- debride cuff edges

- debride GT / tuberoplasty to decrease impingement

- biceps tenotomy / tenodesis

 

Results

 

Boileau et al JBJS Am 2007

- demonstrated good results with tenotomy or tenodesis

- 61 patients with irreparable tears

 

Liem et al Arthroscopy 2008

- 31 patients average age 70

- debridement cuff edges + biceps tenotomy

- no SAD

- reasonable results

 

Walch et al Arthroscopy 2005

- arthroscopic tenotomy in 307 irreparable RC tears

- 87% satisfied with results

 

4.  Suprascapular nerve release

 

Theory

- retraction of cuff tethers / impinges SSN

- release of nerve arthroscopically relieves pain

 

Technique

- arthroscopic release

- see miscellaneous/suprascapular nerve for technique

 

Salvage

 

Indications for tendon transfer / Graft

 

Young patient with poor function

- failed primary repair

- significant weakness

- good deltoid function

- CA arch intact / no superior escape

- good ROM

- either posterosuperior or anterosuperior defect

 

1.  Subscapularis Transfer

 

Disadvantage

- may lose humeral depressor effect

- lose abduction with deltoid

 

Technique

- release upper 1/3 tendon from capsule

 

Results

 

Karas et al JBJS Am 1996

- 20 patients

- good results in 17

 

2.  P.  Major Transfer

 

Indication

- functional deficit from SSC tear

 

Technique

- deltopectoral approach

- use sternal head rerouted under clavicular head for better line of pull

 

Results

 

Jost et al JBJS Am 2003

- reasonable results in isolated SSC

- less so with combined SS and SSC (doesn't recommend)

 

3.  Lat Dorsii Transfer

 

Indications

- IS / SS tear

 

Technique

 

Lateral Decubitus position

- arm over mayo table

 

Standard deltoid splitting open approach to subacromial space

- acromioplasty - minimal, preserve CA arch

- ACJ excision if needed

- tag cuff edges medially with sutures to augment repair

- place lateral anchors / sutures

 

L shaped incision

- inferior margin deltoid, lateral aspect of latissimus dorsi

- arm forward flexed to 90 degrees and IR

- infraspinatous usually very wasted

- identify T major

- find L dorsi below T major, develop interval between the two

- identify tendon insertion on humerus, often have to release T major tendon from it

- place homan over humeral head

- release tendon from insertion / keep long

- is usually thin / 3 cm wide / 5 cm long

- suture each margin with strong suture, leave limbs long to pass tendon

- release muscle belly for length / above and below / must identify and preserve pedicle

- tunnel tendon under deltoid & acromion

- suture anchors repair to GT + subscapularis + medial cuff remnant

- repair with arm in abduction and ER

- maintain in abduction and external rotation splint for 6/52

 

LDTT exposureLDTT intervalLDTT find tendon

 

LDTT homanLDTT tendonLDTT tendon suture

 

LDTT ReleaseLDTT humeral headLDTT repair

 

Pre op Lat Dorsi TransferPost Op Lat Dorsi TransferLat Dorsi Transfer Lateral

 

Results

 

Miniacci JBJS Am 1999

- 14 / 17 good results regarding pain relief and ROM

 

Tauber et al JBJS Am 2010

- compared patients with tendon transfer to those with tendon + bone block

- significantly improved results in bone block

- 4/22 reruptured on MRI in tendon v 0/20 in bone block group

 

4.  Allograft

 

Results

 

Moore et al Am J Sports Med 2006

- 28 patients average age 59

- patella tendon or achilles

- sewn to tendon medially

- bone block laterally or sutured

- 15 repeat MRI - all complete failure of graft

- 1 infection and 1 allograft rejection

- similar functional results to debridement alone

- not recommended by authors

 

5.  Synthetic Allograft

 

Results

 

Nada et al JBJS Br 2010

- dacron graft for massive cuff tears in 17 patients

- sutured medially, tied through bony tunnels laterally

- 90% satisfaction

- 15/17 intact on MRI

- 1 rupture, 1 deep infection

 

6. Arthroplasty

 

CTA Hemiarthroplasty / Reverse TSR

- salvage in patients > 65 years

 

Partial Thickness Tears

Clinical

 

Pain & Stiffness

- often more pain than FT tears

 

Bursal side tears more painful than articular

 

Articular side more common

 

May see in young patient overhead throwing

 

Examination

 

Painful arc

 

Impingement signs

 

No weakness

- function good

- cable system intact

 

Classification

 

Articular sided more common than bursal

 

Ellman

- A (articular)

- B (Bursal)

 

Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed

 

Incidence

 

Sher et al JBJS Am 1995

- 19 - 39 years - 4% PT , no FT

- > 60 years - 26% PT, 28% FT

 

NHx

 

Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT

 

MRI

 

Articular Sided

 

Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear

 

Bursal Sided

 

Arthroscopy

 

Articular side

 

Minor

 

Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear

 

Major

- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage

 

PASAT Arthroscopy 1PASTA Arthroscopy 2

 

Bursal Sided

 

Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear

 

Management

 

Non Operative

 

Physio / HCLA

 

Operative

 

Indications

 

1.  Failure of non operative treatment (6-12 months)

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth

 

Options

 

1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT

 

1.  Acromioplasty + debridement

 

Indications

- < 50% tears

 

Shoulder Scope PASTA Debridement

 

Results

 

Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years

 

Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair

 

Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT

 

Conclusions

- bursal sided tears tend to do more poorly than articular sided

- repair > 50% especially in young patients

 

2.  Acromioplasty and repair

 

May be done open / arthroscopically / arthroscopically + mini open

 

Options

A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open

 

A.  Convert to FT and repair

 

Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction

 

B.  Articular sided / transtendinous PASTA repair

 

Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation

 

Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair

 

C.  Bursal sided

- can repair top layer of tear only

 

Technique Transtendinous Arthroscopic PASTA Repair 

 

Advantage

- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness

 

Technique

 

Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal

 

Shoulder Partial Articular Supraspinatous Tear PASTA

 

Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint

 

A.  Pass bird beak suture passers through cuff to retrieve sutures

 

B.  Pass 20G spinal needle and pass down 0 nylon, retrieve via anterior portal

- tie to thread, and pass suture back through tendon

- do so each time for each thread in horizontal mattress pattern

 

Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled

 

Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ

 

Shoulder PASTA Repair Sutures in Subacromial SpaceShoulder PASTA Repair Knots Tied Subacromial Space

 

Post op

- can range aggressively

- the repair is protected by the intact portion of the tendon

- prevents stiffness

 

Technique Open Articular PT Tears

 

Arthroscopy

- put spinal needle through torn portion

- pass suture through to mark tendon

 

Open approach over needle entry

- identify tear by suture

- convert to FT and repair

 

Technique Arthroscopic Bursal Sided Tear

 

Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion

 

Insert anchor

- pass sutures through top layer of torn tendon

- tie down

 

Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair

Revision Cuff Tears

Incidence

 

Variable

- may be up to 50% retear over time

- many asymptomatic

 

MRI

 

Shoulder MRI Failed Rotator Cuff RepairShoulder MRI Failed RC Repair 2

 

Options

 

1.  Debride / Biceps tenotomy or tenodesis

 

2.  Revision cuff repair

- open

- arthroscopic

 

Revision Rotator Cuff 1Revision Rotator Cuff Repair 2

 

3.  Tendon transfer

 

 

 

 

 

 

Subscapularis Arthroscopic Repair

Technique

- extra-articular

 

Portals

- posterior portal very lateral so can see anterior aspect subacromial space

- port of Wilminton at anterolateral acromion to access SSC

- anterior portal in normal position, slightly more lateral so becomes working portal

 

SSC Repair Portals 1SSC Repair Portals 2

 

GHJ

- identify tendon

- work through portal Wilmington

- grasp, forms comma sign

- perform biceps tenodesis

- tag SSC with fibrewire

 

SSC tornSSC comma sign

 

Subacromial space

- place standard lateral portal as well

- total bursectomy plus acromioplasty

- use tagging sutures to identify SSC

- release as necessary

- may need long posterior cannula to see anteriorly

- may need to move camera to lateral portal to see around corner anteriorly

- can use 70 degree scope

 

SSC Tagging Suture Subacromial SpaceSSC Debridement Anterior Subacromial

 

Prepare footprint

- debride

- insert anchors (retract port of Wilminton into subacromial space)

- pass sutures with suture passer

- tie

 

SSC Debride FootprintSSC First AnchorSSC Suture Passage

 

SSC Second AnchorSSC Repair

 

 

 

 

Subscapularis Tears

AnatomySSC Longitudinal Tear

 

Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus

 

Action

- IR (with T major, P major, Lat Dorsi)

- part of force couplet depressing humeral head

 

Incidence

 

Can be isolated event

 

More commonly seen with SS tears (2% in MRI study)

- anterosuperior tears

 

Associations

- HAGL

- biceps subluxation

- coracoid impingement

 

MOI

 

Trauma

- hyperextension and ER

 

Degenerative

 

Examination

 

Pain anterior shoulder

 

Increased ER

 

Lift off test

 

Belly Press

- elbow falls posteriorly to harvest post deltoid

 

MRI

 

Subscapularis Tear MRISubscapularis FT Tear MRI Glenoid RetractionMRI Retracted Subscapularis TearMRI SSC tear minimal retraction

 

Arthroscopy

 

Complete absence of SSC

 

Subscapularis Retracted Tear Arthroscopy

 

Comma Sign

 

SSC tornSSC Comma Sign

 

Medially Subluxed Biceps

 

Medially Subluxed Biceps

 

Management

 

Operative Indications

 

Degenerative

- failure of 6/12 non operative

 

Trauma

- fix acutely

 

Options

1.  Debridement

2.  Open Repair

3.  Arthroscopic Repair

 

Debridement

 

Results

 

Edwards et al Arthroscopy 2006

- 11 patients with SSC tears

- debridement

- tenotomy in 9 with dislocating / unstable biceps

- 9/11 good results

 

Open Repair

 

Technique

 

Deltopectoral approach

- preserve axillary nerve inferiorly

- mobilise SSC

- subscapular nerves on anterior surface medial to glenoid rim

- tenodesis LHB

- suture anchor repair to lesser tuberosity

 

Results

 

Barti et al Am J Sports Med 2010

- 30 traumatic tears, patient average age 43

- associated biceps subluxation and HAGL's seen

- repair structurally intact in 93%

- 20% still unable to perform lift off / belly press tests

- these patients had higher degree of fatty infiltration preoperatively

 

Arthroscopic Repair

 

Intra-articular technique

- camera in GHJ

- anterosuperior portal

- mobilise tendon front and back

- must remove adhesions

- roughen insertion point on LT / gentle with burr as bone is soft

- insert twinfix anchors x 2 via stab incision

- pass birdsbeak suture passer through portal and through SSC

- retrieve 3 sutures through tendon

- retrieve 4th suture over top of SSC

 

Extra-articular Technique

- see article

 

Results

 

Lafosse et al JBJS Am 2007

- isolated repair in 17 patients

- 15 intact repairs and 2 partial reruptures on CT arthrogram

- good outcomes

 

Late reconstruction

 

P. major transfer

 

Results

 

Jost et al JBJS Am 2003

- good results in isolated SSC tears

- results poor in shoulder arthroplasty

 

Sternoclavicular Dislocations

EpidemiologySCJ Anterior DIslocation

 

Extremely uncommon

Stability provided by joint capsule /costoclavicular & interclavicular ligaments 

 

Recurrent instability uncommon

 

Many apparent dislocations in adolescents may be growth plate injuries 

-will remodel without treatment

 

If OA from chronic dislocation may resect SCJ

 

Types

 

Anterior & posterior 

 

Posterior

- more serious injury

- least common

 

Diagnosis 

- difficult on physical examination

- radiographs often are non diagnostic

- most consistent diagnostic modality = CT

 

Anterior 

 

SCJ CT Anterior DislocationSternoclavicular Anterior Dislocation

 

Usually managed non-operatively

- with activity modification and reassurance

 

MUA 

- often will redislocate

 

Open reduction

- need to stabilise

- can use strip PL to stabilise

- uncertain if any benefit 

 

Posterior 

 

CT Posterior SCJ Dislocation

 

May require treatment because of proximity of major neurovascular structures and airway 

 

1.  Closed reduction

- performed under GA in operating room 

- chest surgeon available

- potential vascular / airway catastrophe associated with injuries to the mediastinum

- thorough vascular exam pre-operatively

 

2.  Assess stability

 

Successful closed reduction usually stable

- avoid internal fixation because of likelihood of hardware migration

- possible injury to the mediastinal structures

 

Closed reduction unsuccessful

- open reduction is indicated

- can stabilize with PL graft / intra-osseous sutures

 

SCJ Open ReductionSCJ Reduction 2SCJ Suture Fixation

 

 

 

Wrist

Arthroscopy

Indications

 

TFCC tears

SL instability

Dorsal wrist ganglion

Scaphoid fracture with percutaneous pinning

Distal radius fracture

 

Setup

 

Tourniquet

 

Finger Traps Index & middle

 

Overhead traction device

 

Wrist Scope set up

 

2.7 mm scope / small joint instrumentation

- insufflate with saline first at 3-4

 

Wrist Scope Insufflation

 

Radiocarpal Joint

 

RCJ is U shaped

 

Portals are between extensor compartments

- longitudinal incisions to protect extensor tendons

- blunt dissection to preserve SRN branches

- angle 30o volar due to shape distal radius

 

Wrist scope portalsWrist scope radiocarpal portal

 

3-4 Portal

- feel Lister's tubercle

- 1 cm distal is soft spot between 3 and 4

- between distal radius and scapholunate

- primary viewing portal

 

4-5 Portal

- roll finger over mobile 4th compartment

- feel soft spot

- slightly proximal to 3-4 because of slope of radius

- between distal radius and lunatetriquetral

- instrumentation

 

6-R and 6-U

- Named after their position about ECU

- 6-R working

- 6-U inflow

 

Midcarpal Joint

 

Anatomy

 

MCJ is S shaped

- midcarpal & radiocarpal have separate synovial cavities unless the SLL is torn

 

Midcarpal radial / MCR Portal

- 1 cm distal to 3/4 portal

- radial side of the third metacarpal axis 

- in line with Lister's tubercle

- soft depression between the capitate and scaphoid

- working portal

 

Midcarpal ulna / MCU Portal

- 1 cm distal to 4/5 portal

- in line with 4th metacarpal

- distal to lunate-triquetral joint

- proximal to capitate and hamate

 

Wrist scope portalsWrist Scope Midcarpal Scope

 

Radiocarpal Joint

 

Start at radial styloid and scaphoid

- work radial to ulnar

 

Distal radius

 

RSC Ligament

- immediately beside is Long RLL

- is extremely wide usually x3 RSCL

- next is short RLL

- often see blood vessels along this ligament

 

Scapholunate ligament

- examine from membranous prox portion to thicker dorsal ligamentous portion

 

Wrist scope SL Ligament Radiocarpal joint

 

TFCC

 

Follow ulnarly along lunate and its fossa 

- should be taut like a trampoline 

- actual ballottement with probe should give same feeling 

- trampoline test

 

Wrist Scope TFCC

 

Examine for tears 

- central or peripheral

- ulnar styloid recess is normal finding at base of styloid not a tear

 

Lunate chondromalacia

 

Midcarpal joint

 

Curved of head of capitate

 

Wrist scope midcarpal joint

 

SL joint

 

Wrist scope midcarpal joint SL jointWrist scope Midcarpal Joint Normal SL ligament

 

Lunate-triquetral joint

 

Wrist Scope Midcarpal Normal Lunate Triquetrum

 

Specific Conditions

 

Carpal Instability

 

SL and LT Ligaments

- must look from radiocarpal and midcarpal joints

- both joint ligaments should be tight and concave

- if inflow in RCJ with midcarpal outflow have tear in ligament

 

Arthroscopic classification

 

1.  Attenuation or haemorrhage within ligament

- no step

- can debride partial tears with good results

- Rx cast immobilisation

 

II. Incongruency or step-off in midcarpal space

- Use k-wire as joy stick to reduce

- treat with arthroscopic pinning

- 80% reported good results

 

III. Step-off on both sides

- pprobe may be passed between bones

- treat with arthroscopic or open repair

 

IV. Gross instability

- open repair

 

TFCC Injuries

 

Use 4-5 portal as visual portal and 6-R as working portal

 

Issues

- degenerative or traumatic

- central or peripheral

- with or without DRUJ instability

- without or without chondromalacia

- radial or ulnar avulsions

- +/- Styloid fracture

 

Techniques

 

Debride central tears acute or degenerative

 

Attempt repair of peripheral tears

 

Unstable DRUJ

- reinforce DRUL or PRUL with strip of ECU

 

Degenerative tear and ulnar plus 

- add ulnar shortening to debridement

- can perform arthroscopic wafer procedure

Base of Thumb OA

Definition

 

Degenerative arthritis at trapeziometacarpal joint (CMC)

- trapezoid - metacarpal

 

Epidemiology

 

Commonest hand joint involved in OA 

 

Most common in older women                                      

- 90% are females > 50 years                                                

- asymptomatic degenerative changes common

 

Associated with arthritis in scapho-trapezial joint in 50%

 

Anatomy

 

1.  Trapeziometacarpal Joint (TMJ)

2.  Scaphotrapezial Joint (STJ)

3.  Trapeziotrapezoidal Joint

4.  Trapezium - Index Metacarpal Joint

 

The last two joints are rarely involved with OA

 

Saddle shaped

- allows movement in 3 planes

- flexion / extension

- adduction / abduction

- opposition

 

Volar, palmar oblique "beak" ligament

- provides stability of TMT

- origin is volar tubercle trapezium

- insertion ulna base of MC

- resists dorsal subluxation

 

Palmar 1/2 loaded > dorsal

- 13 x pressure with pinch

 

Aetiology

 

Primary

 

Combination of                                                                

- high compressive loads                                          

- relatively unstable joint                                              

- complex range of movement

 

May be related to ligamentous laxity

 

Secondary

 

Gout                                                                

Rheumatoid arthritis                                              

Infection                                                                  

Trauma

 

Eaton Classification

 

Stage 1 

 

Joint normal with synovitis 

 

Stage 2 

 

Joint space narrowed                                                    

- may be mild subluxation (< 1/3) 

 

CMC OA Stage 2

 

Stage 3 

 

Joint space obliterated                                                

 

Subluxation base of thumb

- adducted position

- proximally is anchored by adductor pollicis

- base subluxes radially / beak ligament ruptured

 

CMC OA Stage 3

 

Stage 4 

 

Involvement of multiple joint surfaces especially STT joint

 

CMC OA Stage 4CMC OA Stage 4

 

Symptoms

 

Pain at base of thumb especially with pinch grip 

 

Becomes constant / difficulties with ADL 

 

Stiff thumb 

 

Weak pinch grip

 

Examination

 

Base of Thumb OA

 

Tenderness around CMC joint

 

Swelling from 

- synovitis 

- osteophytes 

 

Positive grind test 

- passive thumb circumduction and axial loading 

- causes pain 

 

Web space contracture

- fixed flexion-adduction contracture of 1st MC 

- compensatory MCPJ extension

 

DDx

 

De Quervain's

Radiocarpal OA

SNAC / SLAC

Scaphoid nonunion

Carpal tunnel syndrome 

FCR synovitis 

Volar ganglion

SRN neuroma

 

Management

 

Nonoperative Management

 

Majority of patients do not require surgery

 

Options

 

Rest / static splinting / thumb spica

 

Oral analgesics and NSAIDS

 

Intra-articular steroids / US guided

 

Operative Management

 

1.  Reconstruction of the volar ligament

 

Indication

- stage 1 disease

- non responsive to non operative management

 

Advantages

- minimises progression of degenerative changes

 

Technique

- reconstruction of the volar ligament with slip FCR

- tendon passed through MC base and trapezium 

- create stabilising ligament (tenodesis) 

 

2.  CMC Arthrodesis

 

Indication

- stage II and III disease 

- young manual workers 

- ligamentous laxity and neurological conditions

 

Contraindications

- pantrapezial OA

- i.e. involvement of STJ

 

Advantages

- pain-free 

- strong pinch 

- allows heavy use

 

Disadvantages

 

1.  Limits mobility of thumb MC 

- loss of abduction / adduction

- unable to put palm flat on table

 

2.  Increases stress on adjacent joints 

 

Position

- thumb position when fist made 

- 30-40o palmar abduction 

- 10-15o radial abduction

 

Technique

- dorsal incision at base of thumb over CMCJ

- dorsal to APL, between EPL and EPB

- protect SRN

- protect radial artery as it passes dorsally over STJ

- transverse incision capsule

- cut articular surfaces with saw

- ensure can pinch grip with IF / MF

- ensure can place across palm

- headless compression screws / plate

- POP for 6 weeks

 

3.  Hemitrapeziectomy

 

Removal of distal half of trapezium only

 

4.  Excisional arthroplasty / trapeziectomy

 

Thumb Trapeziectomy

 

Indications

- stage II & III disease

- no significant MC subluxation

 

Technique

- simple excision of trapezium

 

Advantages

- simple procedure 

- minimal immobilisation

 

Disadvantages

- shortening of thumb ray 

- weakness of pinch 

- thumb adduction

 

Results

- trapeziectomy without interposition / ligament reconstruction

- no evidence has worse results than any other more complicated procedure

 

5.  Trapeziectomy and LRTI

 

Indications

- stage III and IV disease 

 

Concept

- trapeziectomy +

- ligament reconstruction of beak ligament with FCR / PL

- tendon interposition (FCR / PL / Capsule)

 

Supposed Advantages

- maintains strength / pinch grip

- prevents shortening

 

Disadvantages

- tendon harvest

- longer / more involved procedure

- no evidence of improvement of pinch grip / prevention of shortening

 

Approach

 

Incision

- dorsoradial

- junction of volar and dorsal skin

 

Dissection

- protect SRN

- between APL and opponens

- radial artery over ST Joint 

- open capsule over trapezium 

- elevate thenar muscles from trapezium and 1st MC 

 

Excise trapezium 

- remove bone piecemeal / or in one piece 

- take care not to damage underlying FCR 

 

LRTI Technique 1

 

Make hole in base of MC 

- perpendicular to plane of thumbnail 

- from radial cortex to base 

 

Harvest lateral half FCR

- 10 - 12 cm strip

- 2 - 3 transverse incisions in forearm over FRC

- split all the way to base of second MT

- pass through base second MT then radial cortex

- pass around base to resurface

- suture to itself whilst pushing MC base medially

 

Make spacer 

- anchovy tendon on itself 

- insert it into trapezium fossa 

 

Stabilise with K wire

- MC reduced and out to length

 

Close wound & apply thumb spica 

 

Postoperative 

- ROS and K wire at 10 days 

- splint for another 3 weeks 

- progressive exercises

 

LRTI Technique 2

 

Harvest PL

- leave attached distally

- pass into base of thumb under FCR to where trapezium used to be

- ligament suspension by passing through radial capsule and FCR multiple times

- tightens the capsule and FCR into the gap

 

Capsular interposition technique

 

Open capsule as a distally base flap

- after trapeziectomy suture into base of wound as interposition

 

Results

- > 90% satisfactory results long-term 

- > 95% pain relief

- > 90% increased grip strength

- average loss of height is 13% at 9 years

 

6.  Silicone replacement arthroplasty

 

Indications

- stage III and IV disease 

- low-demand patient

- rheumatoid

 

Concept

- trapeziectomy

- insert silicone trapezium

 

Advantages

- retains movement at CMC joint

 

Disadvantages

- subluxation or dislocation 

- prosthesis breakage (50% at 4 years) 

- silicone synovitis 

 

Issue

- address subluxation by soft tissue reconstruction 

- strip of APL can be passed through hole in prosthesis 

 

7.  Joint replacement

 

High revision rate

- pain

- lysis

- loosening

 

Carpal Instability

Background

Definition

 

Loss of normal ligamentous and / or bony constraints of wrist

 

Anatomy

 

Overall alignment maintained by extrinsic and intrinsic  ligaments

 

1.  Intrinsic ligaments

 

Carpal bone to carpal bone

- support the lunate in a balanced position

 

A.  Scapho-lunate ligaments

 

SL ligament can be divided into three different zones

- dorsal ligamentous zone (structurally the most important)

- palmar ligamentous zone 

- proximal membranous fibrocartilaginous zone

 

B.  Luno-triquetral ligaments 

- also 3 components

- volar most strong

 

2.  Extrinsic Ligaments

 

Radius to carpus 

- obliquely oriented

- resist the tendency of the carpus to migrate ulnarly and palmarly

 

A.  Palmar extrinsic ligaments

 

A. Radioscaphocapitate ligament

B. Radiolunate ligament

C. Radioscapholunate ligament

- probably just a vascular fold

D. Ulnocarpal ligaments

E. Lunotriquetral ligament

 

Space of Poirier

- weak area of the palmar ligaments

 

B.  Dorsal Extrinsics

 

A. Dorsal radiotriquetral ligament / Dorsal radiocarpal ligament (DRC)

B. Dorsal radioulnar ligament

C. Triquetroscaphoid ligament / Dorsal intercarpal ligament (DIC)

 

No tendons attach to proximal row

 

Note: 

- acess to dorsal carpus

- raise a radially based flap

- between radiotriquetral and triquetroscaphoid

- between DRC and DIC

 

Biomechanics

 

Motion

 

Capitate is centre of rotation

 

Flexion / Extension

- 120o

- 50% midcarpal

- 50% radiocarpal

 

Radial / ulna deviation

- 60% midcarpal

- 40% radiocarpal

 

Radial deviation

- 20o

- proximal row and scaphoid flexes

 

Ulnar deviation

- 30o

- proximal row and scaphoid extends

 

Load transfer

 

Radius 80%

Ulna 20% (all via TFCC)

 

Pathology

 

Division of the scapholunate ligament 

- allows the lunate to follow the triquetrum's unrestrained position of extension

- dorsal intercalated segmental instability pattern (DISI)

- scaphoid flexes, lunate extends

 

Lunotriquetral ligament disruption 

- allows the lunate to follow the scaphoid into its position of unrestrained flexion

- lunate flexes

- volar intercalated segmental instability pattern (VlSI)

 

Classification of Carpal Instabilities (Amadio)

 

I. Carpal instability dissociative (CID)

 

Transverse injury

 

Injury inter-osseous ligaments

- within the carpal rows

- disassociative rather than associative motion between the bones of each row

 

A.Dorsiflexion (DISI)

- scapholunate ligament injury

 

B. Palmar flexion (VISI)

- triquetrolunate injury

 

II. Carpal instability non-dissociative (CIND)

 

Transverse injury

 

Normal associative motion between the bones of each carpal row 

- the dissociation is between rows

 

A. Radiocarpal Dislocation

 

CIND Dislocated Radiocarpal Joint APDislocated Radiocarpal Joint lateral

 

Radiocarpal Dislocation CT 1Radiocarpal Dislocation CT 2Radiocarpal Dislocation CT 3

 

B. Midcarpal

 

C. Ulnar Translocation

 

CIND DISI

 

Secondary to radial malunion

- treat with radial osteotomy if symptomatic

 

DISI CIND Secondary Radial Fracture

 

CIND VISI

 

Secondary to ligamentous laxity

- non operative treatment

- no progression to OA

 

Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation

 

III. Carpal instability complex (CIC)

 

Hyperextension injury

 

As the hand is forced into hyperextension

- ulnar deviation and intercarpal supination

- the ligamentous disruption

 

Mayfield Cadaver study 

- extend, ulna deviate, supinate

 

Stage 1 

- SL dissociation 

 

Stage 2

- CL dissociation 

- capitate dislocates

 

Stage 3

-  LT dissociation

 

Stage 4

-  Lunate dislocates

 

Types

 

A. Perilunate Dislocation

1. Dorsal (10%)

2. Volar (90%)

 

B. Trans-scaphoid Perilunate

 

IV. Carpal instability longitudinal (axial)

 

Longitudinal injury

 

The carpus may also be disrupted in a longitudinal fashion, as opposed to the perilunate transverse pattern

 

Classification

 

A.  Axial Ulnar (AU)

B.  Axial Radial (AR)

C. Axial Ulnar-Radial (AUR) / Combined

 

These are severe injuries

- crush, blast or compression

- may be open injuries

- not a diagnostic dilemma

 

Usually wrist is split into two columns

- metacarpals follow their corresponding carpus

 

Management

 

Deal with wounds and nerve / tendon injuries

CTD

K wire fixation

 

Greater and Lesser Arc Injuries

 

Greater arc injury

- fracture-dislocation of the scaphoid, capitate, hamate, triquetrum

- may include radial styloid

 

Lesser arc injury 

- a pure ligamentous injury

- around the lunate

 

 

 

 

 

Radiocarpal & Midcarpal Dislocation

A. Radiocarpal Dislocation

 

Dislocated Radiocarpal Joint Dislocated Radiocarpal Joint AP

 

Dislocated Radiocarpal Joint CT 1Dislocated Radiocarpal Joint CT 2Dislocated Radiocarpal Joint CT 3

 

Dorsal Radiocarpal Dislocation ORIF 1Dorsal Radiocarpal Dislocation ORIF 2

 

B. Midcarpal Dislocation

 

 

SLAC Wrist

Definition

SLAC Wrist

 

Scapho-lunate advanced collapse

- caused by malalignment of scaphoid on radius

- due to scapholunate disruption

 

Most common cause of wrist OA

 

Pathology

 

1.  Radio-scaphoid degenerative changes

- from abnormal flexion of scaphoid

- scaphoid fossa is elliptical causing incongruence with flexion of proximal scaphoid

- loads scaphoid fossa of radius peripherally

 

2.  Radiolunate joint preserved

- lunate fossa and proximal lunate spherical and congruent

 

3.  Capitate under increasing load descends into gap

- increasing loads on capitolunate joint

- separation of scaphoid and lunate

- capitate shears off radial edge of lunate

- get destruction on both lunate and proximal capitate 

 

X-ray

 

OA radio-scaphoid joint

Preservation of radiolunate joint

 

Staging

 

1.  Styloid OA

 

Stage 1 SLAC Radial Styloid OA

 

2.  Scaphoid Fossa OA

 

SLAC CT

 

3.  Lunato-capitate OA

- capitate descends in SL gap

 

SLAC Lunate Capitate OA

 

4.  Pancarpal OA

 

DDx

 

SNAC

- preservation of scaphoid fossa and proximal scaphoid congruence

- arthritis at scapho-capitate joint

 

Management

 

Stage 1

 

Definition

- styloid OA

- degeneration between the radial styloid and distal pole scaphoid

 

Options

 

1.  Styloidectomy

- early disease can respond well to styloidectomy

- remove at level A / no removal of scaphoid fossa

 

2.  Scapholunate Reconstruction 

 

A.  Excise fibrous tissue and insert SL screw

- fibrous ankylosis

- remove screw at 12/12

 

B.  Bone blocks with ligament

 

Stage 2 

 

Definition

- scaphoid fossa OA

- OA extends to involve scaphoid fossa and proximal pole scaphoid

 

Options

 

A.  Scaphoidectomy & four corner fusion

B.  Proximal Row Carpectomy

 

Scaphoidectomy & Four Corner Fusion

 

Scaphoidectomy and 4 corner fusion

 

Theory

- fusion of lunate to capitate

- loading is through normal lunate fossa

- fusion of lunate-capitate can be difficult

- add hamate and triquetrum in so called 4 corner fusion

- greatly increases fusion rates

- seemingly no deleterious effects

- if leave out scaphoid replacement tends to drift into radial deviation

- can use scaphoid for bone graft (but may not be high quality)

 

Advantage

- increased stability comared with PRC

- increased ROM compared with total wrist arthrodesis

 

Approach

- universal posterior approach

- base of EPL (3/4 interval)

- can use Lister's tubercle for BG

- make window on radial side so as not to get late rupture of EPL

- denervate wrist / remove terminal branch PIN

- ligament sparing exposure / open capsule between dorsal intercarpal and radiocarpal

- closure ER under EPL at end of case

 

Technique

- resect scaphoid

- denude surfaces of lunate / capitate / hamate / triquetrum

- use good quality BG from distal radius

- must reduce the lunate out of extension or will impinge dorsally

 

Scaphoidectomy 4 corner Fusion APScaphoidectomy 4 corner Fusion Lateral

 

Fixation

- headless compression screws

- dorsal circular plate

- K wires

 

Results

- strength 75-80% normal

- ROM 40 - 60% of normal

 

B.  Proximal row carpectomy

 

Proximal Row Carpectomy

 

Aim

- for capitate to articulate with distal radius

 

Disadvantages

- proximal capitate often devoid of good cartilage

- discard good lunate cartilage

- weakness ensues due to lengthening of tendons

- reported pain / instability / degeneration

 

Indications

- probably best in low demand patients

- not in stage 3 SLAC

 

Technique

- perform through standard dorsal approach

 

Results

- RCT of 4 corner fusion v PRC are comparable

 

Stage 3 

 

Definition

 

Capito-lunate OA 

- capitate migrates proximally between the scaphoid and the lunate

 

Options

 

A. Scaphoid excision & 4 corner fusion

B. Proximal Row Carpectomy

C. Wrist Arthrodesis

 

Note

- PRC may be bad options in stage 3

- they depend on the capitate and by definition the capitate is arthritic

 

Stage 4

 

Definition

 

Collapse / pancarpal OA

 

Options

 

Wrist arthrodesis

 

 

Scapholunate Ligament Injury / DISI

Scapholunate Disassocation

 

Definition

 

Dorsal Intercalated Segmental Instability / CID

 

Anatomy

 

Scapholunate joint

- C shaped

- 2-3 mm thick dorsally with transverse fibres

- thin palmar

 

Dorsal extrinsic ligaments

- V shaped, onto trapezium

 

1.  Dorsal RC ligament / DRC

- radius to triquetrum

 

2.  Dorsal Intercarpal Ligament / DIC

- trapezius to scaphoid

 

Between these two ligaments is access to SL joint

 

Volar extrinsic ligaments

 

Radioscapholunate

- ligament of Testut

 

Epidemiology

 

Most common form of carpal instability

 

Classification

 

CID

 

Static

- SL diastasis

 

Dynamic

- positive Kirk Watson test

- nil SL diastasis without dynamic / stress imaging

 

CIND DISI

- secondary to radial malunion

- adaptive posture of proximal row

- lunate extends

- capitate translates dorsally and get OA

- treat with radial osteotomy if symptomatic

 

Aetiology

 

FOOSH

 

Scapholunate dissociation

- Mayfield Stage 1

 

Wrist extended / ulna deviated / supinated

- capitate driven into interval between scaphoid and lunate

 

Pathomechanics

 

CID (Complex Instability Dissociative)

- disassociation between scaphoid and lunate

- Palmarflexion of scaphoid

- dorsiflexion of lunate

 

The scaphoid will move into flexion

- due to its ligamentous attachments to the distal carpal row

 

Lunate extends

- due to ligamentous attachment to triquetrum

 

History

 

History of injury 

Pain on radial side of wrist 

Weakness of wrist 

 

Certain movements may cause clicking or snapping

 

DDx

 

DR / scaphoid fracture

Dequervain's

Neuroma

Ganglion

STT, wrist, RC OA

 

Examination

 

Swelling and tenderness over SLJ

- most specific 

 

Pain with dorsiflexion and radial deviation

 

Kirk-Watson test 

 

Kirk Watson Test 1Kirk Watson Test 2

 

1.  Passive wrist ulnar deviation

- thumb on dorsum wrist / index finger on scaphoid tuberosity 

- in wrists with instability, the scaphoid is displaced dorsally over the lip of the radius

 

2.  Passive wrist radial deviation 

- the scaphoid's proximal pole returns to its position in the scaphoid fossa of the radius 

- as the scaphoid reduces, a clunking sensation and wrist pain are noted

 

1000 randomly examined wrists 

- 11% had unilateral, asymptomatic increased scaphoid mobility on KW test

 

Patients with dynamic instability are distinguished by

- symptoms of instability and pain with KW test

 

X-ray

 

Look for signs of SLAC wrist

- degenerative changes of scaphoid fossa with relative sparing lunate fossa

- indicates long standing

 

AP 

 

Terry Thomas sign 

- increased scapholunate interval 

- > 3 mm compared with other side

 

Scapholunate diasstasis

 

Stress views

- bilateral wrists clenched 

- in ulnar deviation 

- in radial deviation 

- may show Terry Thomas sign

 

Cortical Ring sign 

- end-on view of cortex of distal pole of scaphoid

 

Scapholunate Disassocation Cortical Ring Sign

 

Scaphoid shortened

- due to palmar flexion

 

SL injury shortened scaphoid

 

Lateral

 

Palmarflexion of scaphoid 

 

Dorsiflexion of lunate 

 

Increased scapholunate angle 

- > 70o

- usually 30 - 60o

 

Scapholunate Angle IncreasedScapholunate Angle IncreasedIncreased Scapholunate Angle

 

Increased luno-capitate angle

- normally < 10o

 

Scapholunate Injury Increased Lunate Capitate AngleIncreased Scapholunate Angle

 

Increased radio-lunate angle

- normally < 10o

- lunate extended > 10o

 

MRI

 

Can demonstrate tear

- need experienced radiologist

- need MRI in correct plane

- sensitivity may be as low as 40%

 

Arthroscopy

 

Best method of diagnosis

Gold Standard

 

Acute Management

 

Definition

 

Within 3-6 weeks

 

Options

 

Partial

- immobilise 6 / 52

 

Complete

- SL diastasis

- usually torn off scaphoid

- repair

 

Technique

 

Approach

- dorsal midline approach

- 3 / 4 interval (3rd and 4th extensor compartments)

- open capsule between DRC and DIC ligaments

- radially based flap

 

Reduction

- K wires into scaphoid and lunate

- use as joystick to reduce

- extend scaphoid, some flexion of lunate

- K wire fixation to hold in place (SL and SC x 2)

- neutralises rotational forces during healing

 

Repair

- micro anchors ain scaphoid

- or can place drill holes in scaphoid to pass sutures

- 2.0 ethibond

 

+ / - Augmentation

- Blatt capsulodesis

- SL screw / pseudoarthrosis

 

Post op

- 8 weeks POP

- remove K wires

- patient will lose some ROM

 

Chronic

 

Definition

 

> 12 weeks 

 

Indications

 

Failed reconstruction / missed injury

 

Failed Scapholunate Reconstruction

 

Surgery only for significant disability 

- no reconstructive technique excellent

- inconsistent results, loss of reduction, loss of pain relief over time

 

Options 

 

Ligament repair

Ligament reconstruction

Blatt capsulodesis

Reverse Blatt capsulodesis

Brunelli Tendodesis

Limited wrist fusion

 

1.  Ligament repair and capsulodesis

 

Sufficient tissue available for repair

Reinforce with Blatt capsulodesis

 

2.  Ligament reconstruction

 

Scapholunate Ligament Reconstruction APScapholunate Ligament Reconstruction Lateral

 

3.  Blatt Capsulodesis

 

Indications

- chronic DISI with insufficient tissue for repair

- to augment ligament repair

- dynamic instability

 

Technique

- dorsal, proximally based capsular flap 1 cm wide

- reduce scaphoid out of flexion and K wire (SL / SC)

- suture anchor distal pole scaphoid and attach capsular flap

- prevents flexion of scaphoid

- may combine with SLL reconstruction with PL

 

Post op

- plaster for 2/12

- removal K wires

 

The patients end up with a stiff wrist

 

4.  Reverse Blatt

 

Difference

- leave capsule attached distally

- advance proximally

- limits wrist flexion

 

5.  Brunelli Wrist Tenodesis

 

Harvest half FCR

- pass volar to dorsal through hole distal scaphoid

- insert dorsally into distal radius

- serves to derotate scaphoid

 

6.  Limited fusion 

 

Radial styloidectomy and STT fusion

 

Concept

- stabilise scaphoid in extended position

 

Kleinman J Hand Surg Am 1998

- no progression of arthritis seen in 16 wrists

 

 

VISI

Definition

 

Volar Intercalated Segmental Instability

- secondary to injury to the lunate-triquetral ligament

 

Epidemiology

 

Less common

 

Aetiology

 

Caused by fall on outstretched extended wrist

- hypothenar eminence strikes ground first 

- isolated LT ligament injury

 

Can be part of perilunate dislocation

- SL heals

- residual LT laxity

 

Anatomy

 

LT ligament

- also C shaped

- strongest palmar

 

Pathomechanics

 

Normally

- scaphoid imparts a flexion moment on proximal row

- triquetrum imparts an extension moment

- balanced by ligamentous attachments to lunate

 

Palmarflexion of lunate with dorsiflexion of triquetrum

 

Probably need injury to dorsal extrinsics to impart static collapse

- DRC ligament (radio-triquetral)

- ulnocarpal ligament

 

Classification

 

CID

 

Static

 

Dynamic

 

CIND VISI

 

Secondary to ligamentous laxity

- seen in teenage girls

- clunk on radial and ulna deviation with axial compression

 

Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation

 

Non operative treatment

- no progression to OA

 

Symptoms

 

History of injury 

 

Pain on ulnar side of wrist 

 

Weakness of wrist

 

Signs

 

Swelling and tenderness over triquetro-lunate joint 

 

Ulna deviation / pronation / axial compression

- pain and clicks

 

Reagan Ballotment 

- Triquetro-lunate ballottement

- pisiform-triquetral with thumb and index finger

- lunate with other hand

 

Lunate Triquetral Ballotment

 

DDx

 

DRUJ instability

TFCC tear

Ulna head OA

Pisiform triquetral OA

Hamate fracture

ECU subluxation

 

AP Xray

 

Palmarflexion of scaphoid 

- Scaphoid shortened 

- Ring sign 

 

Palmarflexion of lunate 

- Appears triangular 

- Triquetrum distally displaced 

 

Broken Shenton's line (of proximal carpal row)

 

Lateral Xray

 

Decreased scapholunate angle 

- < 30o

 

Palmarflexion of lunate 

- capitate - lunate angle > 10o

- radio - lunate angle > 10o

 

Arthroscopy

 

Diagnostic and therapeutic

 

Management

 

Early

 

Options

 

A.  Repair

- dorsal approach

- restore LT orientation with K wires

- repair ligament with intra-osseous sutures

 

B Reconstruct with ECU

- if insufficient ligament for repair

- radial half of ECU

- pass through drill holes

 

Late

 

> 6 weeks 

 

Lunate-triquetral fusion

- very difficult

- high failure with k wires

- need compression screws

- insert bone graft

 

 

DDx Radial wrist pain

DOG WRIST RIFT

 

De Quervain tenosynovitis

OA CMC / STT

G   Ganglion - volar 

 

W  Wartenberg's Syndrome (Compression Superficial Branch Radial nerve)

R   Radial artery thrombosis

I    Intersection syndrome (ECRL/B crossed by APL & EPB)

S   Scaphoid fracture / non-union / SL instability / SLAC wrist

T   Tumour

 

R   RA - more common ulna 

I    Infection

F   FCR synovitis 

T   CTS

 

 

DRUJ / TFCC

Anatomy

Anatomy

 

1.  TFCC 

- central articular disc

- TFCC is major stabiliser of DRUJ

- arises ulnar aspect of lunate fossa of radius

- inserts fovea at base of ulna styloid

 

2.  Dorsal and Palmar Radio-Ulna ligaments 

 

Thick fibrous structures

- from ulna styloid

- important stabilises of DRUJ

 

In normal wrist

- Dorsal RU ligament tight in pronation

- Palmar RU ligament tight in supination

 

Unstable wrist is opposite

- in pronation wants to dislocate dorsally 

- PRUL which tightens

- in supination wants to dislocate volar

- DRUL tightens

 

3.  ECU Sheath

 

4.  Ulna Collateral ligament

- arises base of ECU sheath

 

5.  Ulnotriquetral / Ulnolunate ligaments

- ulno-carpal ligaments

- play important role 

- not part of TFCC

 

Conditions

 

TFCC tears

DRUJ instability (acute or chronic)

DRUJ arthritis

 

 

 

DRUJ Arthritis

 

DRUJ ArthritisDRUJ Arthritis

 

Options

 

Darrach's

- distal ulna excision

- best for elderly RA patient

 

Bower's interpositional hemiarthoplasty

 

Technique

- best for young OA

- excision of arthritic portion through 5/6 compartment / hemiresection

- intact TFCC for interposition

 

Indications

- young OA

- not suitable in RA as TFCC damaged

 

DRUJ Hemiresection

 

Suav-Kapanji

 

Technique

- distal radio-ulna arthrodesis with distal ulna pseuodoarthrosis

- distal ulna fused to distal radius with 2 screws

- distal ulna stabilised with half FCU

- interposition with pronator quadratus

 

DRUJ Replacement

 

DRUJ ReplacementDRUJ Replacement

 

 

DRUJ Instability

Types

 

Dorsal

- most common

Volar

 

Causes

 

1.  Acute traumatic peripheral tear TFCC with DRUJ dislocation

- usually major trauma

- dorsal or volar

 

2A.  Distal radial fracture

- Galleazzi fracture

- sigmoid notch fracture

 

2B.  Radial Malunion

 

3.  Ulna styloid fracture

 

4.  Essex Lopresti 

- fracture radial head with dislocation DRUJ

 

Diagnosis

 

Xray

- need true lateral

- ensure radial styloid overlies proximal scaphoid / lunate / triquetram

 

CT

- Axial view shows DRUJ incongruency

 

1A.  Dorsal Dislocation DRUJ

 

Mechanism

- hyperpronation

- tear of dorsal distal RUJ ligament

- with partial or complete TFCC tear

 

Clinically

- dorsal prominence

- forearm locked in pronation

- attempted supination painful

 

CT scan

 

Management

 

1.  Closed reduction

- maintain in supination 4/52

 

2.  Open reduction

- rarely needed

- failure closed reduction (ECU incarceration)

- chronically dislocated

- may require acute repair TFCC +/- K wires

 

TFCC Repair + K wire

 

1B.  Volar Dislocation DRUJ

 

Mechanism

- forced supination

- usually complete tear TFCC

 

Clinically

- arm locked in supination

 

CT scan

 

Management

- closed reduction

- maintain in pronation 4 weeks

- rarely need open reduction or in chronic cases

 

2A.  Acute Distal radial fracture / Galleazzi

 

Incidence

- up to 60%

 

Treatment

- Anatomical reduction of radius

- usually makes DRUJ stable

- rarely need to repair TFCC / K wire for stability

 

2B. Radial malunion / Non anatomical ORIF

 

A. Short radial fracture

- lengthening radius difficult

- ulna shortening

 

B.  Angulation / rotation

- radial osteotomy

- TFCC repair

- +/- TFCC reconstruction with strip ECU

 

3.  Displaced ulna styloid

 

Classification

 

Type 1

- tip fracture

- stable DRUJ

 

Ulna Styloid Tip FractureUlna Styloid Tip Fracture

 

Type 2

- base fracture

- unstable DRUJ

 

Wrist Ulna Styloid Fracture

 

Management

 

POP immobilisation in neutral rotation and UD for 6/52 

- ensure DRUJ remains located

 

Rarely need ulnar styloid ORIF if displaced and DRUJ unstable

 

4. Essex-Lopresti injury

 

Definition

- fracture radial head with dislocation DRUJ

- Essex-Lopresti variant - radial neck fracture with dislocation DRUJ

 

Type 1

- acute radial head fracture

 

Management

- reconstruct or replace radial head

- assess stability in supination

- occasionally need TFCC repair +/- K wire

 

Type 2

- late

- following excision of radial head with injury to interosseous membrane

- usually occurs within first two years following injury

 

Management

 

Nil degenerative changes

- ulna shortening with plate to reduce DRUJ

- radial head replacement to prevent recurrence

 

Degenerative changes

- Hemiresection / Darrach's / Kapandji

TFCC Tears

Definition

 

Present with pain but not instability

 

Types

 

Traumatic

Degenerative

 

Different treatment algorithms for each

 

History

 

Ulna side wrist pain

- may be worse with rotation

- opening doors and jars

 

History of trauma

 

Examination

 

Local tenderness DRUJ

 

Supinate / pronate

- pain

- click

 

Forcibly ulna deviate and pronate wrist

- grinds carpus against TFCC
- generates pain

 

Check for DRUJ instability / Piano Key

 

Ulna variance

 

Position

 

Xray in neutral supination / pronation

 

Variance is not static

- Pronation increases ulnar variance

- Supination decreases variance

- May be up to 3 mm

 

Measurement

 

Transverse line of lunate fossa

Transverse line of ulna head

 

Variation

 

Population is on average 1 mm ulna plus

- wide variation

- 1/4 wrists are ulna negative

 

Importance

 

Neutral variance

- Takes < 20% of load

 

Ulna Variance Neutral

 

2.5mm Ulnar negative

- 4.3% of load

 

Ulna NegativeUlna Variance Negative

 

2.5mm Ulnar positive

- 42% of load

 

Ulna Variance PositiveUlna Positive with abutmentUlna Variance Positive

 

Xray

 

Ulna Variance

 

Evidence ulnocarpal abutment / arthritis

 

MRI

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