OKU REVIEWOKU REVIEWCHAPTER 24 – SHOULDER CHAPTER 24 – SHOULDER

INSTABILITYINSTABILITY

24 year male presents with a 24 year male presents with a traumatic shoulder dislocation traumatic shoulder dislocation that was reduced. He is now 3 that was reduced. He is now 3 days out and in a sling. Which days out and in a sling. Which

of the following is true?of the following is true?A. There is a high likelihood of having a rotator cuff A. There is a high likelihood of having a rotator cuff tear.tear.

B. He will most likely have the same if not better B. He will most likely have the same if not better quality of life and sporting activities once quality of life and sporting activities once rehabilitation starts.rehabilitation starts.

C. He will likely dislocate his shoulder again.C. He will likely dislocate his shoulder again.

D. All of the above are trueD. All of the above are true

24 year male presents with a 24 year male presents with a traumatic shoulder dislocation traumatic shoulder dislocation that was reduced. He is now 3 that was reduced. He is now 3 days out and in a sling. Which days out and in a sling. Which

of the following is true?of the following is true?A. There is a high likelihood of having a rotator cuff A. There is a high likelihood of having a rotator cuff tear.tear.

B. He will most likely have the same if not better B. He will most likely have the same if not better quality of life and sporting activities once quality of life and sporting activities once rehabilitation starts.rehabilitation starts.

C. He will likely dislocate his shoulder again.C. He will likely dislocate his shoulder again.

D. All of the above are trueD. All of the above are true

Describe the difference Describe the difference between laxity and between laxity and

instability.instability.

Describe the difference Describe the difference between laxity and between laxity and

instability.instability.Laxity = objective measurement of joint mobilityLaxity = objective measurement of joint mobility

Instability = subjective symptomatology associated Instability = subjective symptomatology associated with excessive joint motion.with excessive joint motion.

Which of the following are Which of the following are important regarding important regarding

patient history?patient history?A. Direction of instability.A. Direction of instability.

B. Number of episodes of instability.B. Number of episodes of instability.

C. Both A and B.C. Both A and B.

Which of the following are Which of the following are important regarding important regarding

patient history?patient history?A. Direction of instability.A. Direction of instability.

B. Number of episodes of instability.B. Number of episodes of instability.

C. Both A and B.C. Both A and B.

The anterior apprehension The anterior apprehension test is used to test is used to

test/evaluate what type of test/evaluate what type of instabilty?instabilty?

The anterior apprehension The anterior apprehension test is used to test is used to

test/evaluate what type of test/evaluate what type of instabilty?instabilty?

Anterior instabilityAnterior instability

What test is used in What test is used in conjunction with conjunction with

apprehension test?apprehension test?

What test is used in What test is used in conjunction with conjunction with

apprehension test?apprehension test?Relocation test.Relocation test.

What special test is used to What special test is used to evaluate posterior evaluate posterior

instability?instability?

What special test is used to What special test is used to evaluate posterior evaluate posterior

instability?instability?Jerk test.Jerk test.

The sulcus sign evaluates The sulcus sign evaluates what type of instability?what type of instability?

The sulcus sign evaluates The sulcus sign evaluates what type of instability?what type of instability?

Inferior instability.Inferior instability.

What anatomic structure is What anatomic structure is often incompetent when the often incompetent when the sulcus sign is present with sulcus sign is present with

shoulder ext. rotation?shoulder ext. rotation?

What anatomic structure is What anatomic structure is often incompetent when the often incompetent when the sulcus sign is present with sulcus sign is present with

shoulder ext. rotation?shoulder ext. rotation?Rotator interval.Rotator interval.

What x-ray view is What x-ray view is paramount for evaluation paramount for evaluation of shoulder dislocations?of shoulder dislocations?

What x-ray view is What x-ray view is paramount for evaluation paramount for evaluation of shoulder dislocations?of shoulder dislocations?Axillary lateral.Axillary lateral.

Match the x-ray view with Match the x-ray view with the appropriate pair.the appropriate pair.

A. West PointA. West Point

B. Stryker NotchB. Stryker Notch

C. ZancaC. Zanca

1. Hill-Sachs lesion1. Hill-Sachs lesion

2. Bony Bankart2. Bony Bankart

3. AC Joint3. AC Joint

Match the x-ray view with Match the x-ray view with the appropriate pair.the appropriate pair.

A. West Point – 2. Bony BankartA. West Point – 2. Bony Bankart

B. Stryker Notch – 1. Hill-Sachs lesionB. Stryker Notch – 1. Hill-Sachs lesion

C. Zanca – 3. AC JointC. Zanca – 3. AC Joint

What position of the What position of the shoulder reapproximates shoulder reapproximates

the anterior labrum the anterior labrum anatomically?anatomically?Internal rotation (as if in a sling)Internal rotation (as if in a sling)

Slight flexionSlight flexion

External rotationExternal rotation

Neutral rotation and extensionNeutral rotation and extension

What position of the What position of the shoulder reapproximates shoulder reapproximates

the anterior labrum the anterior labrum anatomically?anatomically?Internal rotation (as if in a sling)Internal rotation (as if in a sling)

Slight flexionSlight flexion

External rotationExternal rotation

Neutral rotation and extensionNeutral rotation and extension

What complications results from What complications results from nonanatomic reconstructions of nonanatomic reconstructions of the anterior shoulder (Putti-Platt the anterior shoulder (Putti-Platt

and Magnuson-Stack)?and Magnuson-Stack)?

What complications results from What complications results from nonanatomic reconstructions of nonanatomic reconstructions of the anterior shoulder (Putti-Platt the anterior shoulder (Putti-Platt

and Magnuson-Stack)?and Magnuson-Stack)?1. Significant loss of motion1. Significant loss of motion

2. OA2. OA

According to a recent study According to a recent study involving the Bristow-Latarjet involving the Bristow-Latarjet

procedure, what radiograph was procedure, what radiograph was the most accurate view for the most accurate view for

revealing OA?revealing OA?

According to a recent study According to a recent study involving the Bristow-Latarjet involving the Bristow-Latarjet

procedure, what radiograph was procedure, what radiograph was the most accurate view for the most accurate view for

revealing OA?revealing OA?Subcoracoid projection (angeld inferiorly 45 Subcoracoid projection (angeld inferiorly 45 degrees from above)degrees from above)

The true AP view tended to minimize/miss arthritic The true AP view tended to minimize/miss arthritic changes.changes.

What is the first line What is the first line treatment of treatment of

multidirectional instability?multidirectional instability?

What is the first line What is the first line treatment of treatment of

multidirectional instability?multidirectional instability?Aggressive Physical TherapyAggressive Physical Therapy

Maximize strength and balance of the dynamic Maximize strength and balance of the dynamic stabilizers (cuff, delt, scap)stabilizers (cuff, delt, scap)

Patient EducationPatient Education

Activity ModificationActivity Modification

Match the structure with Match the structure with the appropriate restraint.the appropriate restraint.

A. Posterior Band IGHLA. Posterior Band IGHL

B. Rotator Interval (Coracohumeral and superior B. Rotator Interval (Coracohumeral and superior GHL)GHL)

1. Posterior restraint with the arm flexed, add, IR.1. Posterior restraint with the arm flexed, add, IR.

2. Posterior restraint with the arm in abd2. Posterior restraint with the arm in abd

Match the structure with Match the structure with the appropriate restraint.the appropriate restraint.

A. Posterior Band IGHL – resists posterior A. Posterior Band IGHL – resists posterior translation with the arm in abd (A-2).translation with the arm in abd (A-2).

B. Rotator Interval (Coracohumeral and superior B. Rotator Interval (Coracohumeral and superior GHL) – Posterior restraint with the arm flexed, ADD, GHL) – Posterior restraint with the arm flexed, ADD, IR (B-1).IR (B-1).

What procedure is What procedure is performed after primary performed after primary anteroinferior instability anteroinferior instability

treatment fails?treatment fails?

What procedure is What procedure is performed after primary performed after primary anteroinferior instability anteroinferior instability

treatment fails?treatment fails?Bristow-Latarjet repairBristow-Latarjet repairCoracoid to the anterior glenoid rim transfer.Coracoid to the anterior glenoid rim transfer.

Provides bony reinforcement as well as a soft-tissue sling Provides bony reinforcement as well as a soft-tissue sling of conjoined tendons when the arm is abd and ER.of conjoined tendons when the arm is abd and ER.

Describe the 6 types of AC Describe the 6 types of AC Joint SeparationJoint Separation

Describe the 6 types of AC Describe the 6 types of AC Joint SeparationJoint Separation

Type IType I

Nondisplaced sprainNondisplaced sprain

Type IIType II

Tear AC lig with intact CC ligTear AC lig with intact CC lig

Mild clavicular displacementMild clavicular displacement

Type IIIType III

Comple tear AC and CC ligComple tear AC and CC lig

100% superior displacement of the clavicle100% superior displacement of the clavicle

Type IVType IV

Posterior displacement Posterior displacement

Type VType V

100-300% superior displacement100-300% superior displacement

Type VIType VI

Inferior displacement locked beneath the coracoidInferior displacement locked beneath the coracoid

What type is basically What type is basically always treated nonsx?always treated nonsx?

What type is basically What type is basically always treated nonsx?always treated nonsx?

Type IType I

Which types basically Which types basically always get treated with sx?always get treated with sx?

Which types basically Which types basically always get treated with sx?always get treated with sx?

Types IV, V, VITypes IV, V, VI

What x-ray view is used to What x-ray view is used to help evaluate SC help evaluate SC

instability?instability?

What x-ray view is used to What x-ray view is used to help evaluate SC help evaluate SC

instability?instability?Serendipity viewSerendipity view

40 degree cephalic tilt40 degree cephalic tilt

BUT… CT is accepted as the study of choice.BUT… CT is accepted as the study of choice.

What direction may lead to What direction may lead to major vascular/chest major vascular/chest

injury?injury?

What direction may lead to What direction may lead to major vascular/chest major vascular/chest

injury?injury?Posterior SC dislocationsPosterior SC dislocations