Orthopaedic Knowledge Home Study by R. Alexander

Chapter 24 Shoulder and Arm Trauma: Bone Robert P. Lyons, MD Mark D. Lazarus, MD Clavicle Fractures scapular winging was a common finding accompanying clavicular malunions. The clavicle constitutes the only bony connection be- tween the axial skeleton and the upper extremity. Dis- Indications for open reduction and internal fixation placed clavicle fractures risk injury to the cords of the (ORIF) of acute fractures include open fractures, neu- brachial plexus and subclavian artery and vein, which rovascular injury, or widely displaced fractures that tent, pass between the medial curvature of the clavicle and and may compromise, the overlying skin. Some consider the first rib. Allman’s classification system for clavicle wide displacement and comminution a relative indica- fractures is the most common and divides the clavicle tion for ORIF, citing impaired long-term function and into thirds. Although somewhat arbitrary, this system an increased chance of nonunion. However, the absolute provides an efficient framework to stratify treatment amount of shortening that can be accepted without options and prognosis. functional deficit has not been definitively established. Techniques for fixation include plating or intramedul- Midshaft Fractures lary pinning. Acute Fractures Recent studies documenting the patient-based out- Fractures to the middle third segment are most common comes following nonsurgical treatment of clavicular and account for 81% of all clavicle fractures. Most mid- fractures have shown that results are not as good as dle third fractures heal with a sling or figure-of-8 dress- once believed, with 31% of patients reporting shoulder ing that is provided for symptomatic relief. An epidemi- weakness and fatigability, paresthesias of the hand and ologic study of 535 isolated clavicle fractures found that forearm, and an asymmetric or ptotic shoulder. Frac- 48% of middle third clavicle fractures were displaced tures with greater than 2 cm of shortening have been as- (using 3 mm as the displacement criterion), 19% were sociated with a poor outcome. In addition, significant comminuted, 68% of patients were men, and 61% of comminution associated with displacement also may be fractures involved the left side. an indication for ORIF. A study of 1,430 clavicles from adult skeletons iden- Another study compared 40 patients who received tified 73 clavicular fractures, of which 54 were nonsurgical treatment with a figure-of-8 bandage with malunions. In middle third fractures, the lateral shaft 40 patients who underwent open reduction and in- fragment was consistently displaced posteriorly to the tramedullary fixation with a 2.5-mm threaded pin. Each medial shaft fragment. In contrast, most medial third group consisted of a similar profile of uncomplicated fractures showed anterior displacement of the lateral midclavicular fractures. The group that underwent sur- fragment, often forming a prominent anterior spike. gery experienced a high rate of complications including Twenty-four of 36 clavicles with significant shortening eight superficial infections, three refractures, two de- had overriding of the bone fragments and angulation, layed unions with pin breakage, and two nonunions. which tended to increase in severity the more lateral the These results suggest that nonsurgical treatment ap- fracture. The maximal amount of angulation occurred at pears more advantageous than open intramedullary fix- the coracoclavicular junction, presumably because of ation for the treatment of most midclavicular fractures. the deforming force of the upper extremity’s weight transmitted through the coracoclavicular ligamentous Malunions and Nonunions complex. Although standing AP radiographs of clavicle The incidence of clavicular nonunions has been re- fractures display the inferior displacement of the lateral ported between 0.1% and 15%. Factors that predispose fragment, this study suggests that the principal defor- patients to the development of a clavicular nonunion in- mity in malunions is anterior angulation. Mild fixed clude open fractures, comminuted fractures, or initial shortening greater than 2 cm. Anteroinferior plating of American Academy of Orthopaedic Surgeons 267

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 Figure 1 Radiograph (A) and intraoperative photograph (B) of a symptomatic clavicular malunion. C and D, Biplanar osteotomy with correction of deformity. Fixation was achieved with a 3.5 mm dynamic compression locking plate. No intercalary graft was required. midshaft clavicular nonunions with a 3.5-mm pelvic re- A recent patient-based outcome study of 15 patients construction plate, lag screw, and bone graft has been with clavicular midshaft malunion revealed a mean 2.9 described and resulted in a 100% union rate in 12 pa- cm of clavicular shortening. All patients had major func- tients. The advantages of this technique include a longer tional deficits including chronic pain, shoulder weak- bicortical screw purchase because the anteroposterior ness, and thoracic outlet symptoms for 1 year after in- diameter of the clavicle is much greater than its supero- jury. After corrective osteotomy, it was possible to inferior dimension. The plate in this position acts as a appose two fresh osseous surfaces in all patients without buttress with theoretically less risk of screw pullout the need for intercalary bone graft. The distal fragment from the lateral fragment and less chance of neurovas- was typically rotated such that the flat superior surface cular injury during screw placement. Alternatively, a su- faced anteriorly, and this malrotation was corrected be- periorly placed dynamic compression plate in compres- fore fixation with a 3.5-mm limited contact dynamic sion mode can be used for more transverse fracture compression plate, using a minimum of six holes. This patterns. The newer AO locking plates may be particu- plate was believed to be stronger than the reconstruc- larly advantageous for this indication. Care must be tion plate and easier to contour than the standard com- taken to restore clavicular length and alignment during pression plate. Postoperatively the mean degree of nonunion correction. Prior reports have described the shortening was 0.4 cm and most patients were satisfied use of a locked intramedullary device; however, the res- with the result (Figure 1). toration of length with this device is more difficult. Fi- nally, the use of a vascularized fibula graft to salvage a Distal Third Fractures recalcitrant clavicular nonunion with segmental bone Neer classified distal third clavicle fractures into three loss was described in three patients. Both pain and types. Type I fractures are the most common and remain shoulder function were improved and all patients stable as the conoid and trapezoid ligaments remain in- achieved union. tact. Type II fractures occur medial to the coracoclavicu- 268 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone Figure 2 A through C, fixation methods for type II distal clavicle fractures include coracoclavicular stabilization, using screws or tapes, with or without tension band fixation of the distal clavicular segment. (Reproduced with permission from Lazarus MD: Fractures of the clavicle, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001.) lar ligaments, thus the lateral fragment is usually unsta- fractures and these may delay the diagnosis. The associ- ble and displaced inferiorly with a high incidence of ated mortality rate is 10% to 15% and this outcome nonunion. Type III fractures extend into the acromio- usually is secondary to pulmonary sepsis or head injury. clavicular joint and usually do not involve ligamentous Half of all patients with scapula fractures have other in- injury. sults to the ipsilateral extremity, including vascular and brachial plexus injuries in 13%. Other associated inju- Distal third fractures account for 15% of clavicular ries include hemopneumothorax, pulmonary contusion fractures, and type II distal third fractures have a rate of with rib fractures, and spinal cord injury. Ninety percent delayed union and nonunion between 30% and 45%. of scapula fractures are minimally displaced or nondis- Fixation techniques described in the literature include placed, and thus can be treated nonsurgically. transacromial Kirschner wires, coracoclavicular screws, plates, Dacron tapes, and tension wires (Figure 2). Fixa- Classification tion between the clavicle and coracoid or clavicle and acromion will often fail because it interferes with the The classification of glenoid fossa fractures was recently normal rotation of the clavicle that occurs with arm ele- modified to better estimate scapular body involvement vation. Thus, a second operation is required to remove and provide more consistent guidance for choosing a the fixation before full mobilization is commenced. A surgical approach. Type I injuries represent isolated in- modification of Neviaser’s technique has been de- volvement of the anteroinferior articular surface and scribed, in which two No. 1 polydioxanone sutures are may be associated with a glenohumeral dislocation. used as a superior figure-of-8 tension band between the Treatment is based on instability criteria with fracture fracture fragments. If the distal fragment is too small, fixation, either arthroscopically or through a deltopec- the lateral drill hole can be passed through the acro- toral approach, indicated for fractures that involve more mion because the fixation is absorbable and the acromi- than 25% of the articular surface. Type II fractures in- oclavicular joint is not violated. All fractures healed at 6 volve the superior one third to one half of the articular weeks with no complication. surface in continuity with the coracoid. Types I and II can be treated surgically via a standard deltopectoral A retrospective comparison of type II distal clavicle approach. A Schanz screw used as a joystick or a dental fractures treated nonsurgically versus those that under- pic may aid reduction before fixation with 2.7-mm or went open reduction and coracoclavicular stabilization 3.5-mm cortical screws. was reported. Nonsurgical treatment resulted in a 43% nonunion rate; however, the nonunion had no signifi- Types III, IV, and V fracture patterns involve a vari- cant effect on functional outcome or strength. This study able portion of the lateral border of the scapula and suggests that most type II distal clavicle fractures can be usually require the posterior approach described by Ju- treated nonsurgically. det. Type V patterns, which involve a large separate coracoid or superior articular surface fragment, may re- Scapula Fractures quire a combined Judet and deltopectoral approach. Surgical indications for glenoid fractures have been de- Epidemiology scribed as displacement greater than 5 mm or any dis- placement associated with subluxation of the humeral Scapula fractures account for 3% to 5% of all fractures head. For scapula neck fractures, surgery has been rec- involving the shoulder girdle. Injury to the scapula is ommended if the glenoid is medially displaced greater rare because it is enveloped by a well-developed muscu- than 2 cm or if there is more than 40° of angular dis- lar layer and lies flush with the thorax. However, other injuries occur concomitantly in patients with scapula American Academy of Orthopaedic Surgeons 269

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 placement. Surgical indications for type V fractures in- tion, a significant number of patients may still require clude articular step-off of 5 mm or greater, severe dia- surgical intervention for postoperative stiffness. Unfor- stasis of the articular surfaces, inferior displacement of tunately, associated injuries, especially those to the pe- the glenoid fragment with inferior subluxation of the ripheral or central nervous system, will negatively affect humeral head, or severe disruption of the superior rehabilitation. shoulder suspensory complex. Superior Shoulder Suspensory Complex Injuries Glenoid Fractures The superior shoulder suspensory complex is a bony Glenoid fractures are rare injuries that account for only soft-tissue ring made up of the glenoid, coracoid, acro- 9% to 20% of all scapula fractures, and only 10% of gle- mion process, distal clavicle, acromioclavicular joint, and noid fractures are substantially displaced. Common sur- coracoclavicular ligaments. The superior strut is the mid- gical indications for extra-articular glenoid fractures in- dle clavicle and the inferior strut is the lateral scapula. clude angulation greater than 40°, displacement of the Injury to any two of these elements is believed to result glenoid segment greater than 1 cm, or a fracture associ- in the potential for a large amount of scapula fracture ated with ipsilateral clavicle fracture (such as floating displacement with resultant disability to the patient. It is shoulder). Surgical indications for intra-articular glenoid generally believed that displacement of the scapular rim fractures include displacement greater than 10 mm, neck will alter the relationship of the glenohumeral recurrent glenohumeral instability, or for fractures in- joint with the acromion and create a functional imbal- volving more than 25% of the anterior rim or 33% of ance. However, the exact amount of displacement or an- the posterior rim. Complex intra-articular fractures are gulation required to create this functional imbalance has treated with surgery when there is greater than 5 mm not been quantified. Abduction weakness, decreased displacement or persistent glenohumeral subluxation. range of motion, and nonunion are the frequently impli- Nonsurgical treatment of minimally displaced fractures cated complications of nonsurgical treatment. has been successful. Thus, the decision for surgery must be based not only on fracture character but also on pa- Floating Shoulder Injuries tient age, hand dominance, and activity level. The floating shoulder constitutes a double disruption of Arthroscopic fixation of a displaced posterior gle- the superior shoulder suspensory complex and occurs in noid rim fracture involving more that one third of the only 0.1% of all fractures. In the past, this injury has glenoid cavity has been described. Ligamentotaxis on been considered unstable and thought to require surgi- the surgical extremity held in lateral decubitus traction cal stabilization of one or both elements. Most glenoid was believed to have assisted reduction. neck fractures exit the superior scapular border medial to the base of the coracoid process, near the suprascapu- Glenoid neck fractures are best visualized through a lar notch. This results in a distal fragment consisting of posterior approach, which includes the more limited the glenoid and coracoid process, and a proximal frag- muscle-sparing, or the extensile Judet approaches. A ment consisting of the acromion, scapular spine, and muscle-sparing approach can be used for isolated poste- scapular body. The distal fragment is still attached to the rior glenoid rim or isolated glenoid neck fractures. proximal fragment by the coracoacromial ligament, and through the coracoclavicular ligament and distal clavicu- The incision for the Judet approach begins at the lar fragment by the acromioclavicular capsular liga- posterolateral corner of the acromion, extends along the ments. scapular spine, and then curves inferiorly along the me- dial scapular border. The deltoid is detached from the In one study, 20 patients with a floating shoulder scapular spine and reflected laterally. The infraspinatus were treated nonsurgically and functional scores were is then elevated from the scapular body on its neurovas- equivalent to those from studies involving surgery. Al- cular pedicle and reflected laterally, giving wide expo- though most of the scapula fractures in this study were sure to the posterior scapula. The fracture is identified minimally displaced, the five patients who did have se- and directly reduced. Provisional fixation can be ob- vere displacement of both scapula and clavicle fractures tained with Kirschner wires by passing them through had outcomes comparable to those with minimal dis- the acromion into the glenoid fragment from a superior placement. Nonsurgical treatment of floating shoulder direction. A 3.5-mm reconstruction plate is contoured injuries, especially those with less than 5 mm displace- and applied to the lateral scapular body and posterior ment, is recommended. The criteria for surgical inter- glenoid. Intraoperative radiographs or fluoroscopy is vention needs better delineation. used to confirm anatomic reduction and prevent intra- articular screw penetration. A recent study was the first to directly compare the functional and clinical outcomes of surgical versus non- Postoperative stiffness is a concern. Prophylaxis surgical treatment of displaced ipsilateral fractures of against heterotopic ossification should be considered in the clavicle and glenoid neck. The surgically treated pa- all patients with closed head injury. Despite early mo- 270 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone tients, in whom clavicle and glenoid fractures were Classification fixed, had significantly better forward elevation but had weaker external rotation (possibly related to the surgi- Under Neer’s criteria a segment is nondisplaced when cal approach). It was concluded that patient satisfaction radiographs reveal less than 1 cm of displacement or can be achieved with either surgical or nonsurgical care; less than 45° angulation of any one fragment with re- thus, the decision must be individualized for each pa- spect to the others. The number of fracture lines is im- tient. However, type of treatment was based on surgeon portant only if the displacement criteria are fulfilled. A preference, and the severity of fractures in each group one-part fracture is nondisplaced and is the most com- was not specified. mon type. There are four types of two-part fractures: an- atomic neck, surgical neck, greater tuberosity, and lesser A masked retrospective radiographic review of 20 tuberosity. Three-part fractures involve either a greater patients found that scapular neck fracture displacement, or lesser tuberosity fracture in conjunction with a frac- angulation, and anatomic classification showed moder- ture of the surgical neck. Four-part fractures have dis- ate interobserver reliability by plain films, which was placement of all four segments. Articular surface and not enhanced by CT. CT may be helpful to assess possi- head-splitting fractures are also included in this cate- ble intra-articular extension of a glenoid neck fracture gory. Neer also characterized fracture-dislocations as ei- or occult injury to the superior shoulder suspensory ther anterior or posterior dislocation of the articular complex. However, whether such an injury would ren- segment. Two-, three-, and four-part fractures can occur der the shoulder unstable and require surgical fixation as fracture-dislocations. has yet to be clarified. The AO/Orthopaedic Trauma Association classifica- A recent biomechanical cadaver study testing medial tion system emphasizes the vascular supply to the artic- stability of ipsilateral fractures of the clavicular shaft and ular segment.Type A fractures are the least severe and in- scapular neck did not demonstrate instability (floating volve only one tuberosity with no isolation of the articular shoulder) without additional disruption of the coracoac- segment.Type B fractures are extra-articular, involve both romial and acromioclavicular capsular ligaments. Al- tuberosities, and constitute a low risk of osteonecrosis. though not included in the original description of the su- Type C are intra-articular fractures involving the anatomic perior shoulder suspensory complex, the coracoacromial neck and carry a high risk of osteonecrosis. Each type is ligament is believed to be an important stabilizer of scap- further classified into three subtypes. The complexity of ular neck fractures because it is the only direct ligamen- this classification system has limited its widespread ap- tous connection between proximal and distal fragments. peal. Proximal Humeral Fractures Much attention has been given to the poor interob- server reliability of Neer’s classification documented by Epidemiology some studies. However, a recent study showed that kappa values for interobserver variation improved substantially Fractures of the proximal humerus account for 4% of among physicians who underwent two 45-minute training all fractures. The current incidence is 70 fractures per sessions compared with a control physician group who did 100,000 people and is likely to increase because these not receive training in the Neer system. Another study fractures are related to both patient age and osteoporo- showed that 8 of 22 patients who underwent surgery for sis. Eighty-five percent of these fractures are nondis- three- and four-part fractures of the proximal humerus did placed or minimally displaced and respond to treatment not correspond to any category of the Neer or AO clas- with immobilization followed by early motion. sification system.Articular surface orientation on plain ra- diographs (medially oriented or not) appeared to be more Risk factors for fracture of the proximal humerus indicative of remaining soft-tissue attachments to the were evaluated with data collected from the European head. Whether this factor has validity in predicting os- Patient Information and Document Service study, which teonecrosis or functional outcome has yet to be deter- prospectively followed 6,901 white women who lived in- mined. dependently at home. Overall, the incidence of proximal humeral fracture was 6.6 per 1,000 person-years, which Two-Part Surgical Neck Fractures occurred at a mean age of 82.2 years. The incidence of proximal humeral fracture in women with osteo- In the two-part surgical neck fracture, the pectoralis ma- porosis and a low fall risk score (5.1 per 1,000 woman- jor acts as a deforming force and displaces the shaft me- years) was only slightly higher than in women who did dially and anteriorly. Closed reduction is often possible. not have osteoporosis (4.6 per 1,000 woman-years), and If the fragments are impacted, axial traction is applied. similar to the incidence in women without osteo- Then a gentle posteriorly and laterally directed force is porosis but a high fall risk score (5.5 per 1,000 woman- applied to the upper arm as the shaft is flexed and years). brought underneath the head. The fragments are then impacted and stability is evaluated. The surgeon should American Academy of Orthopaedic Surgeons 271

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 Figure 3 AP (A) and axillary (B) radiographs of a three-part proximal humeral fracture treated with percutaneous pinning. alic vein, biceps tendon, and musculocutaeous nerve from the anterior pin. The shoulder should be externally rotated during placement of greater tuberosity pins and these pins should engage the cortex of the humeral neck 20 mm from the inferior most aspect of the humeral head. Finally, great care should be used to place threaded pins into but not through the subchondral re- gion of the humeral head (Figure 3). Intramedullary rodding has been advocated by some and has shown an 85% success rate in younger patients. However, concerns over poor proximal locking-screw purchase and subsequent proximal rod migration in older patients with osteoporotic bone limit its appeal in this patient population (Figure 4). In addition, ante- grade intramedullary rods violate the rotator cuff and articular cartilage. Locked intramedullary nailing of proximal humeral fractures is best indicated for use in patients with multiple trauma or pathologic fracture. Heavy nonabsorbable sutures have been shown to be an attractive choice for fixation of two- and three-part fractures, especially in those patients with osteoporotic bone. The use of sutures allows the incorporation of the rotator cuff as a fixation point and precludes any chance of hardware failure. Figure 4 Pullout of an antegrade intramedullary humeral nail in an elderly patient. Two-Part Greater Tuberosity Fractures be aware of an oblique surgical neck fracture pattern Isolated fractures of the greater tuberosity are fre- (low anteromedial to high posterolateral), which is usu- quently missed. In one study, 58 of 99 fractures (58%) ally irreducible by closed means. If the reduction cannot were initially overlooked. There was a 64% rate of be maintained, then either closed reduction with percu- missed diagnoses in one-part (nondisplaced greater tu- taneous pinning or ORIF is performed. berosity fracture) compared with a 27% rate of missed diagnoses in Neer two-part fractures. The presence of Percutaneous pinning also carries a risk to neurovas- tenderness on the lateral wall of the greater tuberosity cular structures. At risk are the main trunk of the axil- (distal to the insertion of the rotator cuff) is an effective lary nerve and posterior humeral circumflex artery from clinical sign to confirm the correct diagnosis. Greater tu- the greater tuberosity pin, the anterior branch of the ax- berosity fractures occur in 5% to 15% of anterior gleno- illary nerve from the proximal lateral pin, and the ceph- humeral dislocations. After age 50 years, the incidence of nerve injury with proximal humeral fracture- dislocations as determined by somatosensory-evoked potentials is 50%, and this includes axillary nerve as well as infraclavicular brachial plexus injuries. Displaced 272 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone greater tuberosity fractures can be associated with rota- blood flow to the humeral head when the anterior hu- tor cuff tears, but in many surgical cases, the cuff re- meral circumflex artery has been interrupted. Plates mains intact and only a capsular rent is observed. If ra- were applied lateral to the bicipital groove to avoid in- diographs do not adequately show the fracture jury to the anterior humeral circumflex artery. No signif- displacement, a CT scan may be necessary. In addition, icant relationship was found between the method of fix- ultrasound can detect occult nondisplaced greater tuber- ation (cerclage wire versus plate) and the development osity fractures. of osteonecrosis. Although most patients in this study who had four-part fractures developed osteonecrosis, Most authors advocate conservative treatment of frac- the results were generally good. tures with less than 5 mm displacement and surgery for displacement greater than 5 mm. Given the literature to Newer fixation devices have led to improved tech- date, any greater tuberosity fracture displaced 5 mm or niques for ORIF of two-, three-, and four-part fractures more should be treated with reduction and fixation. of the proximal humerus. The use of a blade plate and interfragmentary sutures has been shown to provide Isolated screw fixation of greater tuberosity frac- firm fixation and a good functional result in the treat- tures should be used only in younger patients because, ment of 34 three-part and 8 four-part fractures of the with aging, the bone of the tuberosity becomes fragile proximal humerus in elderly patients. The blade plate and prone to comminution. The fracture can be fixed has primarily been used for two-part surgical neck frac- percutaneously with arthroscopic assistance. The supe- tures. The use of a blade plate and autogenous cancel- rior approach typically permits easier fragment reduc- lous bone graft resulted in good or excellent results in tion, whereas the deltopectoral approach allows easier 80% of patients with two-part nonunions (and in 90% suture placement. The edge of the fragment can be of low two-part nonunions). Low two-part nonunions aligned with the edge of the fracture bed of the proxi- were easier to treat because the proximal fragment is mal humerus. The sutures are passed around the greater larger and thus easier to secure. tuberosity and through the attachment of the rotator cuff tendons and then cross in a figure-of-8 fashion The advent of the locking compression plate, with a across the fracture site to avoid overreduction of the plate specifically designed for the proximal humerus, is fragment. Because no hardware is used, there is no con- an excellent new option for ORIF of proximal humeral cern about hardware failure. Subacromial scarring, even fractures. With this technique, it is crucial that the surgi- without displacement and capsular contracture, may cal approach preserve soft-tissue attachments as much limit motion postoperatively. This complication is best as possible. It is mandatory to use the drill guide that avoided by initiating passive range-of-motion exercises threads directly into the screw hole in the plate because early in the postoperative period. this ensures that the screw threads will engage precisely with the plate threads. Locking screws will not bring the Three- and Four-Part Fractures plate to the bone, which is not a critical feature of the technique (as opposed to the standard dynamic com- In three-part fractures, one tuberosity is displaced and pression plate) and may actually increase the blood sup- there is a displaced unimpacted surgical neck fracture that ply to the bone and enhance the biology of healing. allows the head to be rotated by the attached tuberosity. Four-part fractures involve displacement of all four seg- Some plate-bone contact may be required to im- ments (the greater and lesser tuberosities, the articular prove fracture alignment and diminish the prominence segment, and the shaft), and the articular fragment is usu- of the implant. This goal can be accomplished by using a ally devoid of soft-tissue attachments. Three- and four- few standard (nonlocking) screws. A mechanical study part fractures represent 13% to 16% of proximal humeral in cadavers showed that the locking compression plate fractures. Surgical modalities have included plates, pins, for the proximal humerus was a more elastic implant screws, staples, intramedullary nails, wires, sutures, or any than the spiral blade, T-plate, and humeral nail, a prop- combination of these, and arthroplasty. Neer preferred erty making this plate less likely to fail in osteoporotic ORIF for two- and three-part fractures and arthroplasty bone, compared with the other implants. for four-part fractures. Others have approached all three- and four-part fractures that are amenable to stable inter- Valgus-Impacted Three- and Four-Part Fractures nal fixation with minimal osteosynthesis. The valgus-impacted pattern of a proximal humeral Osteonecrosis of the humeral head after four-part fracture is characterized by preservation of the postero- fracture of the proximal humerus has an incidence of medial capsular attachments to the humeral articular 21% to 75%, which is believed to be the result of the in- surface. Radiographically, this pattern is defined by the jury pattern itself. It is important to preserve the as- alignment between the medial shaft and head segments. cending branch of the anterior humeral circumflex ar- The results of treatment of the three-part valgus- tery, which is the primary vessel supplying the humeral impacted fracture variant are better than for the stan- head. The posteromedial vessels may preserve some dard Neer three-part fracture. The intact posteromedial American Academy of Orthopaedic Surgeons 273

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 soft tissue supplying residual perfusion to the humeral to allow for stable fixation, tuberosity fragments that in- head is presumably responsible for a better prognosis clude a substantial portion of the articular surface, and with the valgus-impacted fracture. In a recent study, inability to obtain an acceptable reduction. These pa- 80% of patients had a good or excellent result by Neer’s tients are best treated with hemiarthroplasty or total outcome criteria with nonsurgical care. Patients will re- shoulder arthroplasty depending on the condition of the gain only 80% of abduction and flexion strength but do glenoid surface and rotator cuff. not require full motion or strength to return to daily ac- tivities. Hemiarthroplasty is primarily indicated for displaced four-part fractures. Tuberosity osteolysis, malunion, and A new technique of minimal fixation for valgus- nonunion are implicated as the main causes of failure. impacted fractures of the humeral head has been intro- Late arthroplasty after failed primary treatment of duced. An open technique without any sharp deep soft- proximal humeral fractures improves pain, range of mo- tissue dissection was used, and the split between the tion, and function, but most authors have found that the tuberosities was opened to allow elevation of the im- results of late arthroplasty are inferior compared with pacted humeral head fragment. The tuberosities were proximal humerus fractures treated acutely with hu- reduced to hold the humeral head fragment in place and meral head replacement. repaired with heavy absorbable suture (No. 2 Vicryl) be- tween the rotator cuff insertions. No bone grafting, Kir- Prognostic factors in prosthetic replacement for schner wire, or additional fixation was used. No attempt acute proximal humeral fractures were studied in 32 pa- was made to secure the head to the shaft because the tients retrospectively. Fracture type, gender, and type of fracture configuration was considered stable. For 11 pa- prosthesis were found to be irrelevant with respect to tients with an average age of 55 years, the mean outcome. Increased age and an increased preoperative follow-up was 69 months. The mean Constant-Morley delay correlated with a poorer clinical outcome. Patients score as a percentage compared with the opposite side who had surgery within 14 days had a better general was 86%. One patient (9%) developed osteonecrosis. outcome. This study showed a strong correlation be- This rate of osteonecrosis was similar to other reported tween the radiologic position of the tuberosities and the rates using closed techniques. Most of the soft-tissue dis- quantitative as well as qualitative clinical outcome. Tu- section occurred at the time of fracture, so if the princi- berosity complications were the most common compli- ple of minimal further disruption of the soft tissues is cation and were seen in 50% of patients. Humeral offset adhered to, an open technique such as this should not is defined as the distance between the geometric center increase the rate of osteonecrosis. of the humeral head and the lateral edge of the greater tuberosity. The average humeral offset of patients with a Role of Arthroscopy good or excellent outcome (25.39 mm) was significantly higher than the average offset in patients with unsatis- Arthroscopy was used to preoperatively assess 80 shoul- factory outcomes (20.20 mm). Patients with a humeral der fractures, including 52 proximal humerus fractures, offset of 23 mm or more had a significantly better out- 20 fracture-dislocations, and 8 glenoid and/or scapula come. Also, patients with a head height of 14 mm or less fractures. Overall, 20% of fractures were found to have had a better outcome. Lateralizing the tuberosities re- a full-thickness supraspinatus and/or infraspinatus cuff sults in a better outcome and their distal transfer causes tear and 30% had partial tears. Eighteen percent had a poorer outcome. Stable fixation and anatomic reposi- subscapularis tendon tears. Two-part fractures had a tioning of the tuberosities must be achieved during sur- 31% incidence of complete labral tear, whereas only gery. 10% of three- and four-part fractures had a complete la- bral tear, presumably because more energy is dissipated In a similar study reviewing outcome of hemiarthro- at the fracture site in the more complex patterns. Proxi- plasty for fractures of the proximal humerus, it was de- mal humeral fracture-dislocations showed a 56% inci- termined that early surgical intervention within 2 weeks dence of complete labral tear. of injury and accurate tuberosity reconstruction were two factors that were found to have the greatest impact Role of Arthroplasty on functional outcome. The height of the superior hu- meral articular surface with respect to the greater tuber- Incongruity of the humeral head or complete detach- osity is termed the head-to-tuberosity distance (HTD) ment of the articular blood supply are the main indica- and is 8 ± 3 mm as measured in cadaver specimens. The tions for humeral arthroplasty, which typically includes tuberosity was considered malreduced if the fragment some three-part fractures, most four-part fractures, hu- was superior to the humeral head or if the HTD was meral head-splitting injuries, and humeral head impres- greater than 20 mm. sion defects involving greater than 40% of the articular surface. Other factors that may favor arthroplasty in- Proper height was established by placing the articu- clude excessive comminution, inadequate bone quality lar surface of the prosthetic head at the midpoint of the glenoid, and with gentle traction, the prosthetic head re- mained within the glenoid fossa. The humeral compo- 274 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone nent was cemented in all patients and the tuberosities transepicondylar axis had posterior migration of the were then reconstructed so that the greater tuberosity greater tuberosity and a poor functional result. was overlying the lateral fin or was repaired to the ante- rior fin in a three-fin design. Other studies indicate that In a related study, shoulder arthroplasty for the when a prosthesis is inserted for fracture, the lateral fin treatment of sequelae of fractures of the proximal hu- should be a mean distance of 5.2 ± 2.6 mm from the merus was evaluated. The most significant factor affect- posterior edge of the bicipital groove. In a recent bio- ing functional outcome was greater tuberosity osteot- mechanical study, it was shown that a horizontal circum- omy. All patients who underwent greater tuberosity ferential cerclage suture passed through the medial hole osteotomy had either fair or poor results and did not re- of the prosthesis and around the tuberosity fragments gain active elevation above 90°. Whenever possible, os- substantially improves fracture stability, and, in theory, teotomy of the greater tuberosity should not be done, minimizes the potential for nonunion of the tuberosities. and the prosthesis should be implanted by attempting to adapt the implant to the modified anatomy. This goal is Another study considered an HTD of 3 to 20 mm as accomplished by changing the inclination or offset of a an anatomic reconstruction. Acceptable alignment and modular prosthesis. All complications concerning the position of the tuberosities was achieved in 79% of pa- greater tuberosity (nonunion, bone resorption, and tu- tients. The most common complication was malreduc- berosity migration) occurred after osteotomy. Another tion of the greater tuberosity in the vertical plane. In pa- study showed that 10 of 24 patients who underwent os- tients with a nearly anatomic reduction of the greater teotomy had a complication related to tuberosity non- tuberosity, American Shoulder and Elbow Surgeons and union, malunion, or resorption. the Simple Shoulder Test scores, patient satisfaction, and motion were all significantly better than in those pa- A promising surgical option for severe tuberosity tients in whom an anatomic reduction was not achieved. nonunions or long-standing surgical neck nonunions Superior migration was associated with pain, impinge- may be a reverse prosthesis. In theory, by placing a “gle- ment, and motion loss. These patients either had a nosphere,” the proximal humerus can gain a motion ful- malunion or nonunion of the tuberosities. It is now rec- crum without the necessity of a rotator cuff centering ommended that the greater tuberosity be placed 10 mm force. There are long-term risks associated with this im- below the superior articular surface of the humeral plant, including glenoid notching and fracture and loos- head, but not overreduced, as this places the supraspina- ening of the glenoid component. Also, implantation is tus under increased tension and jeopardizes tuberosity technically demanding. Long-term efficacy studies are fixation. Technical errors that can result in an increased needed to determine if a reverse prosthesis is the an- HTD include humeral lengthening by cementing the swer for these difficult reconstructive cases. prosthesis proud, using a head segment that is too thick, and overreduction of the greater tuberosity distal to its Nerve Injury normal anatomic location. A prospective study of 143 consecutive proximal hu- Reasons for poor outcomes after hemiarthroplasty merus fractures found evidence of nerve injury by elec- for displaced fractures of the proximal humerus have tromyography in 67% of patients. The axillary nerve was been analyzed. Initial tuberosity malposition was found involved in 58% and the suprascapular nerve in 48%. A to be present postoperatively in 27% of patients and tu- combination of nerve lesions was frequently seen. As berosity detachment and migration were noted in 23%. might be expected, nerve lesions were more common in Final tuberosity malposition was present in 50% and displaced fractures. Although the nerve lesions recov- correlated with an unsatisfactory result, superior migra- ered in all patients, restoration of shoulder function was tion of the prosthesis, stiffness, weakness, and pain. The less favorable. This finding has implications for patients worst association was a prosthesis that was too high and treated both surgically and nonsurgically. too retroverted with a low greater tuberosity. This “un- happy triad” was associated with migration of the Humeral Shaft Fractures greater tuberosity and proximal migration of the pros- thesis under the acromion in all cases. The functional re- Acute Fractures sults after hemiarthroplasty for three- and four-part proximal humerus fractures are directly associated with Since Sarmiento’s original description in 1977, func- tuberosity osteosynthesis. Lengthening of the prosthesis tional bracing has been considered the gold standard greater than 10 mm because of a proud prosthesis sig- treatment for acute humeral shaft fractures. One recent nificantly correlated with tuberosity detachment and study revealed a 95% union rate in patients. The rate of proximal migration of the prosthesis. The most common nonunion has been reported as low as 1.5% for closed mistake was excessive retroversion of the prosthesis. All fractures and 5.8% for open fractures with the brace re- patients with retroversion exceeding 40° relative to the moved between 10 and 13 weeks. Varus angulation after treatment with functional bracing is common. However, the angulation in most patients is usually functionally and cosmetically acceptable. The high rate of union and American Academy of Orthopaedic Surgeons 275

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 no chance of postsurgical infection imply an earlier re- teopenic bone, and in patients with overlying burns and turn to daily function and a lower cost of care. in those with multiple traumas. The advantages of in- tramedullary nailing over plate fixation include preser- Transverse fracture patterns are the most likely to vation of fracture hematoma and local blood supply, develop angular deformity. Axial distraction between smaller surgical incision, a load-sharing as opposed to a the fragments implies a high level of soft-tissue injury, stress-shielding device, and the theoretical advantage of and these fractures are more likely to develop delayed earlier weight bearing. However, immediate weight union or nonunion. In general, fractures at various lev- bearing in acutely plated fractures has also been shown els heal at the same speed and with similar degrees of to have no detrimental effect. angulation. It is not necessary for the brace to fully cover every proximal or distal fragment. The brace Recent biomechanical studies show increased initial should begin approximately 1 inch (2.5 cm) distal to the fracture stability when nails are inserted antegrade for axilla and should terminate 1 inch proximal to the hu- proximal humeral shaft fractures and retrograde for dis- meral condyles. Supra-acromial and supracondylar ex- tal humeral shaft fractures. Intramedullary nails can be tensions are unnecessary. Active exercises may begin as inserted for shaft fractures in the region 2 cm distal to soon as symptoms allow. However, active abduction and the surgical neck and 3 cm proximal to the olecranon elevation of the shoulder must be avoided until after the fossa. The nonunion rate for intramedullary nailing was fracture is clinically stable because these movements shown to be 5.6%, a rate comparable to that for plating. may produce angular deformities. However, a complication rate of 19% for humeral locked nailing indicates that the procedure is not simply Indications for surgical intervention include open benign and noninvasive. Antegrade nailing carries the fractures, segmental and pathologic fractures, bilateral risk of shoulder pain and disability in 16% to 37% of humeral fractures, fractures associated with vascular in- patients. Retrograde nailing has a significantly higher juries, fractures where radial nerve palsy develops after risk of surgical comminution, and this comminution sig- reduction, multiple trauma with substantial chest/head nificantly increases the risk of nonunion. Great care injuries, floating elbow injuries (ipsilateral fractures of must be taken to avoid anterior cortical notching during both forearm and arm), obesity that prevents adequate retrograde reaming. In addition, radial nerve explora- reduction, severe neurologic disorder, and inability to tion has been recommended before intramedullary rod- maintain satisfactory alignment. For a patient in the re- ding of distal third spiral fractures regardless of the cumbent position for an extended period, it is difficult presence or absence of nerve palsy because the radial to control the fracture with closed treatment. Also, pa- nerve is in imminent danger when intramedullary rod- tients with concomitant chest injury are poor candidates ding is attempted with this fracture pattern. for sling and swathe treatment. Alignment is considered acceptable with up to 20° anterior angulation, 30° of Several studies in recent years have compared plate varus angulation, and 3 cm of shortening. fixation of humeral shaft fractures with intramedullary devices and have reached different conclusions. In re- A radial nerve palsy sustained during humeral frac- ports in which plate and intramedullary rod fixation are ture is not an indication for exploration of the nerve or directly compared, the rate of complications associated for internal fracture fixation. However, whenever the with intramedullary rodding appears higher than that nerve is explored and the fracture is not healed, internal associated with plate fixation. The complications associ- fixation is recommended. Patients with associated bra- ated with intramedullary rodding are related to rates of chial plexus injury should undergo internal fixation be- union (which appear to be somewhat lower than after cause stabilization of the humeral fracture allows earlier plate fixation) and increased functional symptoms such rehabilitation of the injured extremity. Fractures that oc- as shoulder pain and weakness. Complications such as cur in the proximal and distal quarters of the humerus infection, radial nerve palsy, delayed union, and failure without an intervening diaphyseal fracture component of fixation seem to occur at an equivalent rate with both should be treated separately. These fractures are ex- types of intervention. posed through separate incisions and fixed with sepa- rate plates. A prospective multicenter study reported the first clinical results of the Locking Compression Plate (Syn- Plate osteosynthesis has been the most accepted thes, Paoli, PA) in 169 fractures in 144 patients, includ- method for surgical treatment of both acute humeral ing 45 humeral fractures. In 86% of all fractures treated, shaft fractures and nonunions. The rate of union after healing occurred within the expected time period and compression plate fixation has been reported to be without complication. The 1.5% infection rate was low greater than 95%. The disadvantages include consider- considering the heterogenous sample with numerous able soft-tissue stripping, poor screw purchase in os- open fractures and many revision surgeries. This report teoporotic bone, difficulties in complex fractures, and provided several guidelines regarding when to use com- the risks associated with hardware removal. pression technique or a bridging technique with the locking compression plate. Compression technique can Closed intramedullary nailing is considered for pathologic fractures, segmental fractures, fractures of os- 276 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone be used for joint fractures and simple metadiaphyseal fractures, which is in contrast to the good results fracture patterns. The bridging technique is recom- achieved for exchange nailing of femoral and tibial non- mended for multifragmentary metadiaphyseal and dia- unions. physeal fractures. A combined approach is warranted in only two situations: (1) in joint fractures with multifrag- Humeral nonunion defects of 6 cm or greater mentary metadiaphyseal components, the compression present a reconstructive challenge. A vascularized bone technique should be used for the joint and bridging graft remains alive, does not resorb, maintains its struc- technique used for the metadiaphyseal segment; (2) in tural characteristics, and can hypertrophy, thus increas- two-level fractures with different fracture patterns, the ing its structural integrity. The healing of a vascularized compression technique is used for the simple fracture bone graft is a process similar to acute fracture healing, part and the bridging technique for the multifragmen- in contrast to the long-standing process of creeping sub- tary segment. stitution, which must be endured with a nonvascularized allograft. The technique involves the creation of an in- Nonunion tramedullary dowel of the vascularized fibula graft that is placed in the medullary canal of the humerus. The Nonunion is defined as lack of union after 24 weeks. graft is impacted 1 to 2 cm at each end and the con- Nonunion of the humeral shaft occurs in 2% to 10% of struct is stabilized with a 4.5-mm dynamic compression nonsurgically treated fractures and up to 15% of frac- plate (Synthes, Paoli, PA). The fibula is applied as an on- tures treated by primary ORIF. An increased incidence lay graft if the construct is already stable, as with a re- of nonunion can be seen with open fractures, high- tained intramedullary rod. The peroneal artery is usually energy injuries, bone loss, soft-tissue interposition, un- anastomosed end-to-side with the brachial artery. The stable or segmental fracture patterns, impaired blood peroneal vein is anastomosed end-to-side with either supply, infection, and initial treatment with a hanging the venae comitantes of the brachial artery, or the ba- arm cast. Preexisting elbow or shoulder stiffness can silic or cephalic vein. According to one recent study, 11 cause increased motion at the fracture site and predis- of 15 humeral nonunions united with this technique. pose to nonunion. Obesity, osteoporosis, alcoholism, Three of these 11, however, sustained a fracture of the malnutrition, smoking, and noncompliance are all pa- fibula transplant at a mean of 8 months postoperatively tient factors that may increase the risk of nonunion. and required additional bone grafting and plating but progressed to healing. Three other patients with early A 98% consolidation rate was reported after ORIF fixation failure underwent plating and bone grafting and of humeral nonunion using an anterolateral approach eventually healed. One patient developed an infection and autogenous bone grafting. A wave plate was applied and required a second vascularized fibula graft. Three in two instances when an intramedullary nail was in patients had early revision of the venous anastomosis place and its removal was believed to be too hazardous. because laser Doppler readings were below 40% of the Only 2 of 51 patients had a transient sensory radial neu- initial reading for 30 minutes and clinical observation of ropathy. An anterolateral approach with routine identi- the skin island showed questionable perfusion. Only 5 fication and ample release of the radial nerve well be- of 15 patients regained nearly normal function, illustrat- yond the nonunion ensures a very low rate of radial ing the complexity of the humeral reconstruction. nerve injury. This broad exposure allows a plate of suffi- cient length to be applied, which increases the probabil- Annotated Bibliography ity of union. Clavicle Fractures A recent study reported on results of the use of wave-plate fixation and autologous bone grafting in the Edelson JG: The bony anatomy of clavicular malunions. management of humeral nonunion with a retained in- J Shoulder Elbow Surg 2003;12:173-180. tramedullary nail. None of the patients had a prominent nail, which might represent a source of shoulder pain. Seventy-three fractures and 54 malunions were found in a Healing occurred in all six patients at a mean of 16 study of 1,430 clavicles from adult skeletons. A consistent pat- weeks postoperatively. The 4.5-mm wave plates were tern of clavicular shortening involving anterior-posterior angu- bent at two different locations so that the middle por- lation is described. tion of the plate was standing 5 to 10 mm off the bone at the level of the nonunion. At least three bicortical Grassi FA, Tajana MS, D’Angelo F: Management of screws were applied proximally and distally. Autologous midclavicular fractures: Comparison between nonopera- cancellous graft was packed under the elevated portion tive an open intramedullary fixation in 80 patients. of the plate at the site of nonunion. A high rate of non- J Trauma 2001;50:1096-1100. union has been shown after exchange nailing of humeral This study compared figure-of-8 bandaging to intramedul- lary fixation for midclavicular fractures and found that nonsur- gical treatment appeared more advantageous for most patients with midclavicular fractures. American Academy of Orthopaedic Surgeons 277

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 Levy O: Simple minimally invasive surgical technique Schandelmaier P, Blauth M, Schneider C, Krettek C: for treatment of type 2 fractures of the distal clavicle. Fractures of the glenoid treated by operation: A 5 to 23 J Shoulder Elbow Surg 2003;12:24-28. year follow-up of 22 cases. J Bone Joint Surg Br 2002;84: 173-177. A minimally invasive technique is described in 12 patients, which uses absorbable suture fixation to treat Neer type II dis- The results after ORIF of 22 displaced glenoid fractures tal clavicle fractures. Union was achieved in all fractures with with a mean follow-up of 10 years is described. At follow-up, no complications. the median Constant score was 94%. The score was less than 50% in four patients, including two patients who developed an McKee MD, Wild LM, Schemitsch EH: Midshaft infection. malunions of the clavicle. J Bone Joint Surg Am 2003;85- A:790-797. Williams GR Jr, Naranja J, Klimkiewicz J, Karduna A, Iannotti JP, Ramsey M: The floating shoulder: A biome- Fifteen patients who had a malunion following nonsurgical chanical basis for classification and management. J Bone treatment of a clavicle fracture underwent corrective osteot- Joint Surg Am 2001;83-A:1182-1187. omy through the original fracture line and internal fixation without bone graft. The mean amount of clavicular shortening After a standardized neck fracture was made in 12 cadaver was 2.9 cm preoperatively and 0.4 cm after surgery. shoulders, the resistance to medial displacement was deter- mined following sequential creation of an ipsilateral clavicle Postacchini F, Gumina S, DeSantis P, Albo F: Epidemiol- fracture, coracoacromial ligament disruption, and acromioclav- ogy of clavicle fractures. J Shoulder Elbow Surg 2002;11: icular capsular disruption. In another group, resistance to me- 452-456. dial displacement was determined following sequential release of the coracoacromial and coracoclavicular ligaments. Ipsilat- An epidemiologic study of 535 isolated clavicle fractures eral scapular neck and clavicle fractures do not produce a during an 11-year period was performed. Most patients (68%) floating shoulder until the coracoacromial and acromioclavicu- were men. The left side was involved in 61% and fractures of lar capsular ligaments are disrupted. the middle third were the most common (81%). Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Proximal Humeral Fractures Cuomo F, Gallagher MA: A comparison of nonopera- tive and operative treatment of type II distal clavicle Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, fractures. Bull Hosp Joint Dis 2002;61:32-39. Mole D: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced This retrospective study compared nonsurgical and surgi- fractures of the proximal humerus. J Shoulder Elbow cal treatment of type II distal clavicular fractures. At an aver- Surg 2002;11:401-412. age follow-up of 53.5 months, 7 of 16 patients that were treated nonsurgically had a nonunion. However, nonunion had The results of hemiarthroplasty for displaced proximal hu- no significant impact on functional outcome or strength. meral fractures is evaluated. Final tuberosity malposition oc- curred in 33 patients (50%) and correlated with superior mi- Scapula Fractures gration of the prosthesis, stiffness, weakness, and persistent pain. Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and func- Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, tional results. J Bone Joint Surg Am 2001;83-A:1188- Sinnerton R: Shoulder arthroplasty for the treatment of 1194. sequelae of fractures of the proximal humerus. J Shoul- der Elbow Surg 2001;10:299-308. Nineteen patients with a floating shoulder injury were compared with respect to fracture healing, functional outcome, Seventy-one sequelae of proximal humeral fractures were patient satisfaction, and muscular strength. Treatment was treated with shoulder arthroplasty with the same modular nonsurgical in 12 patients and surgical in 7 patients. There was prosthesis (Aequalis) in this multicenter study. The most sig- no significant difference between groups with regard to the nificant factor affecting functional outcome was greater tuber- three functional outcome measures. osity osteotomy. Surgeons should accept the distorted anat- omy of the proximal humerus and adapt the prosthesis to the McAdams TR, Blevins FT, Martin P, DeCoster TA: The modified anatomy if possible, to avoid tuberosity osteotomy. role of plain films and computed tomography in the evaluation of scapular neck fractures. J Orthop Trauma Brorson S, Bagger J, Sylvest A, Hobjartsson A: Im- 2002;16:7-10. proved interobserver variation after training of doctors in the Neer system: A randomized trial. J Bone Joint Scapular neck fracture displacement, angulation, and ana- Surg Br 2002;84:950-954. tomic classification showed moderate interobserver reliability by plain films and was not enhanced when supplemented with Fourteen doctors were randomly assigned to two training CT. CT may be useful to assess associated injuries to the supe- sessions or to no training and asked to categorize 42 pairs of rior shoulder suspensory complex, which could be missed plain radiographs of proximal humerus fractures according to when using plain films alone. the Neer system. The kappa value for interobserver variation 278 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone improved (especially for specialists) from 0.30 to 0.79 with for- Mighell MA, Kolm GP, Collinge CA, Frankle MA: Out- mal training in the Neer system. comes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 2003;12:569-577. Court-Brown CM, Cattermole H, McQueen MM: Im- pacted valgus fractures of the proximal humerus. The re- Eighty shoulders that had been treated with hemiarthro- sults of non-operative treatment. J Bone Joint Surg Br plasty for proximal humeral fractures were reviewed. Tuberos- 2002;84:504-508. ity complications occurred in 16 shoulders. Healing of the greater tuberosity more than 2 cm below the humeral head In this retrospective study of 125 patients with valgus- correlated with a worse functional result. impacted fractures of the proximal humeral, all were treated nonsurgically. At 1-year follow-up, 80.6% of patients had a Ogawa K, Yoshida A, Ikegami H: Isolated fractures of good or excellent result. the greater tuberosity of the humerus: Solutions in rec- ognizing a frequently overlooked fracture. J Trauma Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y: 2003;54:713-717. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma 2003;17: Isolated greater tuberosity fractures were overlooked in 58 181-189. of 99 shoulders (59%) that had been initially examined at other clinics. A smaller fragment correlated with a higher rate This retrospective study investigated the effect of radio- of missed diagnosis. The presence of tenderness on the lateral logic and other factors on the outcome of prosthetic replace- wall of the greater tuberosity is a clinically effective method to ment in 32 patients with acute proximal humeral fractures. The avoid a missed diagnosis. humeral offset was directly correlated to the amount of for- ward elevation and Constant score. The head height was in- Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, versely correlated to the same parameters. Bigliani LU: Two-part and three-part fractures of the proximal humerus treated with suture fixation. J Orthop Frankle MA, Ondrovic LE, Markee BA, Harris ML, Lee Trauma 2003;17:319-325. WE III: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002; The radiographic and clinical outcomes of patients with 11:413-420. displaced two- and three-part proximal humeral fractures that were treated with nonabsorbable cuff-incorporating sutures This biomechanical study compared the stability of differ- were reviewed. Both groups had similar outcomes; some resid- ent reconstructive techniques of tuberosity reattachment for ual deformity did not preclude an excellent outcome. proximal humeral head replacement in four-part fractures us- ing eight fresh-frozen cadaver shoulders. Mercury strain Ring D, McKee MD, Perey BH, Jupiter JB: The use of a gauges were used to measure bony fragment displacement blade plate and autogenous cancellous bone graft in the during cyclic loading. Repairs that used a medial circumferen- treatment of ununited fractures of the proximal hu- tial cerclage had significantly lower displacements and strains. merus. J Shoulder Elbow Surg 2001;10:501-507. Hockings M, Haines JF: Least possible fixation of frac- A blade-plate with autogenous cancellous graft was used tures of the proximal humerus. Injury 2003;34:443-447. to treat proximal humeral nonunions in 25 patients with a mean age of 61 years. Union was achieved in 23 of 25 patients An open technique with no deep dissection is described (92%). The results were classified as good or excellent in 20 of for the fixation of valgus-impacted proximal humeral frac- 25 patients. tures. No bone grafting, Kirschner wires, or other fixation was used. The mean Constant-Murley score as compared with the Robinson CM, Page RS: Severely impacted valgus prox- opposite side was 86%. imal humerus fractures. J Bone Joint Surg Am 2003;85- A:1047-1055. Lee SH, Dargent-Molina P, Breart G: Risk factors for fractures of the proximal humerus: Results for the Twenty-five patients with severely impacted valgus proxi- EPIDOS prospective study. J Bone Miner Res 2002;17: mal humeral fractures were treated with open reduction, fixa- 817-825. tion with screws or a buttress plate, and the fracture defect was filled with Norian Skeletal Repair system bone substitute. The EPIDOS study evaluated 6,901 white women age 75 All fractures united within the first year and no patient had years and older. The examination included measurements of signs of osteonecrosis at latest follow-up. The functional result femoral neck bone mineral density, calcaneal ultrasound pa- continued to be satisfactory for the 12 patients who were fol- rameters, a functional clinical examination, and lifestyle ques- lowed for 2 years. tionnaire. The incidence of proximal humerus fractures was greatly increased in women who had osteoporosis and a high Rowles DJ, McGrory JE: Percutaneous pinning of the risk score for falling. proximal part of the humerus: An anatomic study. J Bone Joint Surg Am 2001;83-A:1695-1699. American Academy of Orthopaedic Surgeons 279

Shoulder and Arm Trauma: Bone Orthopaedic Knowledge Update 8 In 10 fresh-frozen cadaver shoulders the intact proximal Fifteen patients with an average 9.3-cm segmental humeral humerus was pinned using fluoroscopic guidance and a stan- defect were treated with osteoseptocutaneous fibular trans- dard published technique. The specimens were dissected to de- plant. This treatment can be successful but has a high rate of termine the distance of each pin from vital neurovascular complications. structures. Some modifications of technique and a knowledge of local anatomy are needed to avoid injury to the axillary Koch PP, Gross DF, Gerber C: The results of functional nerve, musculocutaneous nerve, and biceps tendon. (Sarmiento) bracing of humeral shaft fractures. J Shoul- der Elbow Surg 2002;11:143-150. Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster MS: Biomechanical testing of the LCP: How can stabil- Sixty-seven humeral shaft fractures were treated by ity in locked internal fixators be controlled? Injury Sarmiento bracing over a 15-year period. At a mean of 10 2003;34(suppl 2):B11-B19. weeks, 87% had healed clinically. Among nine cases of delayed or nonunion leading to surgery, there were six cases with A biomechanical analysis including axial stiffness and tor- transverse fractures. Reasons for failed nonsurgical treatment sional rigidity, fatigue testing, and finite element analysis were included incorrect indication, significant axial deformity, and a undertaken to evaluate the locking compression plate. Opti- hyperextended position of the fracture fragments. mal use of the locking compression plate as it relates to bio- mechanical principles is discussed. For comminuted fractures Lin J, Shen PW, Hou SM: Complications of locked nail- of the humerus, it is recommended that innermost screws be ing in humeral shaft fractures. J Trauma 2003;54:943- placed as close to the fracture as practicable. The distance be- 949. tween the plate and the bone should be kept small. Long plates should be used to provide sufficient axial stiffness. Delayed unions, nonunions, and acute humeral shaft frac- tures in 159 patients were treated with humeral locked nails Visser CP, Coene LN, Brand R, Tavy DL: Nerve lesions and followed for an average 25.4 months. Surgical comminu- in proximal humeral fractures. J Shoulder Elbow Surg tion was significantly higher in retrograde nailing and surgical 2001;10:421-427. comminution and significantly increased the risk of nonunion. Other complications included functional shoulder impairment, Fourteen consecutive proximal humeral fractures were angular malunion, and postnailing radial nerve palsy. evaluated with electromyograms in this prospective study. The electromyogram showed denervation in 96 patients (67%), Marti RK, Verheyen CC, Besselaar PP: Humeral shaft with the axillary (58%) and the suprascapular nerves (48%) nonunion: Evaluation of uniform surgical repair in fifty- most frequently involved. one patients. J Orthop Trauma 2002;16:108-115. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, This article presents a review of the standard treatment of Marti RK: Open reduction and internal fixation of three aseptic humeral shaft nonunions involving an anterolateral ap- and four-part fractures of the proximal part of the hu- proach, radial nerve identification, compression plating, and merus. J Bone Joint Surg Am 2002;84-A:1919-1925. autogenous bone grafting. This approach is reliable and achieves union without a significant risk of complications. The long-term results were assessed for 60 patients with a three- or four-part fracture of the proximal humerus who had Ring D, Jupiter JB: Internal Fixation of the humerus undergone ORIF with cerclage or a T-plate. Thirty-seven per- with locking compression plates. Tech Shoulder Elbow cent of patients had development of osteonecrosis and 77% of Surg 2003;4:169-174. these had a good or excellent Constant score. The drawbacks of previous methods of internal fixation Humeral Shaft Fractures for humeral fractures and nonunions is discussed. The advan- tages of and technique for the application of Locking Com- Gerber A, Marti R, Jupiter J: Surgical management of pression Plates to humeral fractures and nonunions is pre- diaphyseal humeral nonunion after intramedullary nail- sented. Preliminary results are also discussed. ing: Wave-plate fixation and autologous bone grafting without nail removal. J Shoulder Elbow Surg 2003;12: Sommer C, Gautier E, Muller M, Helfet DL, Wagner M: 309-313. First clinical results of the Locking Compression Plate (LCP). Injury 2003;34(suppl 2):B43-B54. Sic patients with a nonunion of the humeral diaphysis af- ter intramedullary nailing were treated with a wave-plate and A prospective multicenter study of the combined Euro- autologous bone grafting. Union can be achieved without re- pean and American experience with the new locking compres- moval of the intramedullary device. sion plate system used to treat various fractures in 144 pa- tients is presented. In this study, tibial fractures (n = 46) and Heitmann C, Erdmann D, Levin LS: Treatments of seg- humeral fractures (n = 45) predominated. General principles mental defects of the humerus with an osteoseptocuta- for the application of the locking compression plate to dif- neous fibular transplant. J Bone Joint Surg Am 2002;84- ferent fracture configurations as well as to humeral fractures, A:2216-2223. are discussed. The low infection rate (1.5%) in this heteroge- 280 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 24 Shoulder and Arm Trauma: Bone nous sample with numerous open fractures and revision pro- Hintermann B, Trouillier HH, Schafer D: Rigid internal cedures attests to the good “biology” of the implant. fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br 2000;82:1107-1112. Stannard JP, Harris HW, McGwin G Jr, Volgas DA, Alonso JE: Intramedullary nailing of humeral shaft frac- Mayo KA, Benirschke SK, Mast JW: Displaced fractures tures with a locking flexible nail. J Bone Joint Surg Am of the glenoid fossa: Results of open reduction and in- 2003;85-A:2103-2110. ternal fixation. Clin Orthop 1998;347:122-130. A flexible humeral nail is described that allows both ante- McCormack RG, Brien D, Buckley RE, McKee MD, grade and retrograde insertion and static locking without vio- Powell J, Schemitsch EH: Fixation of fractures of the lating the rotator cuff or humeral articular surface. Although shaft of the humerus by dynamic compression plate or the nail functioned well in most patients, the use of the smaller intramedullary nail: A prospective, randomized trial. (7.5 mm) nail was associated with a higher complication rate. J Bone Joint Surg Br 2000;82:336-339. This implant should be used with caution in any patient with a medullary canal diameter of 8 mm or less. Momberger NG, Smith J, Coleman DA: Vascularized fibular grafts for salvage reconstruction of clavicle non- Classic Bibliography union. J Shoulder Elbow Surg 2000;9:389-394. Chapman JR, Henley MB, Agel J, Benca PJ: Random- Schai PA, Hintermann B, Koris MJ: Preoperative arthro- ized prospective study of humeral shaft fracture fixa- scopic assessment of fractures about the shoulder. Ar- tion: Iintramedullary nails versus plates. J Orthop throscopy 1999;15:827-835. Trauma 2000;14:162-166. Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD: Effect Edwards SG, Whittle AP, Wood GW II: Nonoperative of immediate weightbearing on plated fractures of the treatment of ipsilateral fractures of the scapula and humeral shaft. J Trauma 2000;49:278-280. clavicle. J Bone Joint Surg Am 2000;82:774-780. Galatz LM, Iannotti JP: Management of surgical neck Webber MC, Haines JF: The treatment of lateral clavicle nonunions. Orthop Clin North Am 2000;31:51-61. fractures. Injury 2000;31:175-179. Herscovici D Jr, Saunders DT, Johnson MP, Sanders R, DiPasquale T: Percutaneous fixation of proximal hu- merus fractures. Clin Orthop 2000;375:97-104. American Academy of Orthopaedic Surgeons 281



Chapter 25 Shoulder Instability Andrew D. Pearle, MD Frank A. Cordasco, MD Natural History the rotator cuff muscles, biceps, and periscapular mus- cles. In general, the capsular ligaments provide stability The glenohumeral joint is the most mobile articulation at end range of motion; however, during midrange of in the body and the most commonly dislocated diarth- motion, the capsuloligamentous structures are lax and roidal joint, with peaks in the incidence of dislocation the joint is stabilized by dynamic joint compression. occurring during the second and sixth decades of life. In- Glenohumeral instability occurs when there is a defi- stability of the glenohumeral joint ranges from subtle ciency in the bony, soft-tissue, or dynamic muscular re- increased laxity to recurrent frank dislocation. No single straints to translation of the humeral head on the gle- disease or lesion is responsible for all types of shoulder noid. Rehabilitation following instability episodes is instability, and treatment has evolved to anatomically directed toward optimizing the dynamic stabilizers, address specific lesions. whereas surgical intervention restores the static stabiliz- ers. Traumatic injury is the major cause of shoulder in- stability, accounting for approximately 95% of shoulder The oval glenoid is longest in its inferior-superior di- dislocations. The sequela of traumatic anterior disloca- ameter and has a nearly flat articular surface. Although tion is associated with the age of the patient at the time the osseous shape of the glenoid does not contribute of initial dislocation and the degree of injury. Age at the greatly to stability, the peripheral chondral surface of time of the initial dislocation is inversely related to the the glenoid is thickened, creating a concave articular recurrence rate. In patients younger than 20 years of surface that augments glenohumeral stability. The la- age, recurrent dislocation rates may be as high as 90% brum is a fibrous structure firmly bound to the glenoid in the athletic population. The rate of recurrences drops at its inferior margin and bound more loosely superi- to 50% to 75% in patients 20 to 25 years of age. In pa- orly, where it is confluent with the origin of the tendon tients older than 40 years, anterior dislocation is associ- of the long head of the biceps. The labral tissue contrib- ated with lower rates of redislocation, but high rates of utes to glenohumeral stability by deepening the glenoid rotator cuff tears. Although the incidence of rotator cuff by approximately 50%. The labrum is thought to act as tears in patients older than 40 years at the time of initial a “chock block” and has been shown to decrease resis- dislocation is 15%, this incidence reaches 40% in pa- tance to humeral translation by 10% to 20%. In addi- tients older than 60 years. The degree of injury (pres- tion, the labrum serves as an attachment site connecting ence and size of Bankart tear, presence and size of os- the glenoid to the capsule, ligaments, and biceps tendon. seous lesions including Hill-Sachs defects and osseous Bankart lesions, capsular tears such as a humeral avul- The capsule of the glenohumeral joint is lax under sion of the glenohumeral ligament, and the presence of normal circumstances, which allows for great range of associated rotator cuff pathology) is directly related to motion of the joint. The capsule attaches medially to the the recurrence rate. glenoid and labrum and extends lateral to the surgical neck of the humerus. In addition to providing structural Pathophysiology stability, the capsule maintains the negative joint pres- sure, which creates a negative vacuum that augments The normal humeral head translates only 1 mm from joint stability. the center of the glenoid during active motion. The gle- nohumeral joint is stabilized by both static and dynamic The ligaments of the glenohumeral joint are discrete stabilizers. The static restraints consist of the glenoid la- bands that insert onto the glenoid labrum. The most im- brum, the articular anatomy, negative intra-articular portant ligaments in the glenohumeral joint are the pressure, joint fluid adhesion, and the capsuloligamen- superior glenohumeral ligament (SGHL), the middle tous structures. Dynamic stabilizers of the joint include glenohumeral ligament (MGHL), and the inferior gle- nohumeral ligament complex (IGHLC) (Figure 1). American Academy of Orthopaedic Surgeons 283

Shoulder Instability Orthopaedic Knowledge Update 8 Figure 1 Schematic drawing of the shoulder capsule showing the glenohumeral liga- liquely across the subscapularis tendon to its humeral ments highlighting the IGHLC. A, anterior; P, posterior; B, biceps tendon; AB, anterior attachment on the lesser tuberosity. A Buford complex band; AP, axillary pouch; PB, posterior band; and PC, posterior capsule. (Reproduced is a normal anatomic variant defined by the absence of with permission from O’Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and the superoanterior aspect of the labrum and a broad, histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports cord-like MGHL. The MGHL prevents anterior transla- Med 1990;18:449-456.) tion when the shoulder is externally rotated and in the middle range of abduction. The SGHL originates on the superoanterior rim of the glenoid, just anterior to the biceps origin, and The IGHLC is the major static anterior stabilizer of courses across the rotator interval to the lesser tuberos- the glenohumeral joint, especially during abduction and ity adjacent to the bicipital groove. The SGHL is the pri- external rotation (Figure 2). The complex consists of an mary static restraint to inferior translation of the ad- anterior and posterior band as well as the axillary ducted shoulder. The coracohumeral ligament (CHL) is pouch. It originates from the inferior labrum and inserts an extra-articular structure that arises from the base of on to the humeral neck. Detachment of the anterior la- the coracoid and passes between the supraspinatus and brum and anterior IGHLC is referred to as a Bankart subscapularis, forming the roof of the rotator interval. It lesion and has classically been understood as the “essen- is composed of an anterior and posterior band that in- tial” lesion in traumatic anterior instability (Figure 3). serts onto the lesser and greater tuberosity, respectively. However, in cadaveric models, minimal translation has The CHL is a static restraint to anteroinferior transla- been noted with recreation of this lesion, suggesting that tion in the adducted shoulder. capsular and ligamentous plastic deformation is an im- portant pathologic component of instability. In a recent The MGHL has the most variable morphology of study using MRI to quantitate the amount of capsular the ligaments; however, no distinct variation in its struc- elongation in patients with recurrent anterior disloca- ture has been correlated with increased rates of instabil- tions, the authors showed that the anterior and inferior ity. The MGHL normally originates in the upper third of portions of the shoulder capsule are elongated an aver- the anterior glenoid rim and labrum and courses ob- age of 19% compared with the unaffected contralateral shoulder. A recent cadaveric study has demonstrated that the posterior band of the IGHLC shows greatest strain in flexion and internal rotation, the provocative positions for posterior instability. This finding suggests that the posterior band of the IGHLC is a static posterior stabi- lizer and should be firmly repaired in patients with pos- terior instability. Dynamic stabilization of the glenohumeral joint oc- curs through joint compression by the rotator cuff, pri- marily the subscapularis and infraspinatus. Dynamic joint compression from the rotator cuff musculature limits superior-inferior translation and imparts stability during abduction. The dynamic joint compression force from the rotator cuff muscles is more important for sta- bility than the static glenohumeral ligaments. The scapu- lar stabilizers, including the trapezius, rhomboids, latissi- mus dorsi, serratus anterior, and levator scapulae position the glenoid in an anteverted and superior posi- tion and provide dynamic coverage for the retroverted humeral head; this increases the posterior and inferior stability of the glenohumeral joint during motion. The biceps tendon is thought to be a dynamic stabi- lizer of the joint, particularly at middle and lower eleva- tion angles. The tendon provides stability in the anterior and superior direction, imparting more posterior stabil- ity in external rotation of the humerus and anterior sta- bility with internal rotation. In addition, because of the intimate association of the bicipital anchor and the SGHL and MGHL, lesions that involve the bicipital an- chor, such as superior labral anterior and posterior 284 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 25 Shoulder Instability Figure 2 The glenohumeral ligaments provide static restraint in different functional positions. A, With the shoulder in adduction and external rotation, the ligament SGHL and MGHL are taut while the anterior band (AB) and posterior band (PB) of the IGHLC are lax. B, With the shoulder in abduction and external rotation, the AB of the IGHLC tightens and the SGHL and MGHL become lax. (Reproduced with permission from Warner JP, Boardman ND III: Anatomy, biomechanics, and pathophysiology of glenohumeral instability, in Warren RF, Craig EV, Altcheck DW (eds): The Unstable Shoulder. Philadelphia, PA, Lippincott-Raven, 1999, pp 51-76.) (SLAP) tears, may increase anteroposterior as well as superoinferior glenohumeral translation. Patient Evaluation Multiple static and dynamic structures contribute to shoulder stability; therefore, proper classification of shoulder instability is essential to identify injured struc- tures and plan treatment. Shoulder instability is classi- fied by the degree, frequency, etiology, and direction of instability (Table 1). Patient history and physical exami- nation should focus on accurately classifying the insta- bility pattern. History Figure 3 Schematic drawing of the anatomy of the Bankart lesion demonstrating avulsion of the capsulolabral structures off the inferior rim of the glenoid. A = anterior; A careful history is essential to begin to classify the pa- P = posterior l(Reproduced with permission from Warner JP, Caborn DNM: Overview of tient’s instability. The etiology of the instability may be shoulder instability. Crit Rev Phys Rehabil Med 1992;4:145-198.) readily apparent as the patient may describe a frank trau- matic dislocation event, history of repetitive microtrauma Physical Examination with overhead activity, or generalized laxity that is famil- ial. Patients are usually able to clearly describe the fre- Examination of shoulder instability begins with a thor- quency and chronicity of instability episodes. Pain or in- ough evaluation of the cervical spine. Careful inspection stability with particular movements or positions may reveal the direction of instability. Patients with anterior in- stability report symptoms with the arm in an abducted and externally rotated position. Posterior instability often oc- curs with the arm flexed, internally rotated, and adducted. Patients may experience symptoms while pushing open a door or heavy object. Patients with inferior instability of- ten have pain while carrying heavy objects; they may also experience traction paresthesias. American Academy of Orthopaedic Surgeons 285

Shoulder Instability Orthopaedic Knowledge Update 8 Table 1 | Classification of Shoulder Instability Imaging Degree Acute traumatic shoulder dislocations are evaluated Dislocation with a trauma series that includes an AP, transscapular Subluxation (Y) lateral, and an axillary view. The axillary view is es- pecially important to confirm reduction. In more Microinstability chronic instability, additional views are useful to assess Frequency bony anatomy and identify characteristic pathologic le- Acute (primary) sions. The West Point axillary view, which is taken with Chronic the patient prone, the arm in 90° of abduction and neu- tral rotation, and the x-ray beam directed 25° posterior Recurrent to the horizontal plane and 25° medial to the vertical Fixed plane, shows the anterior glenoid rim and may reveal Etiology bony Bankart lesions. The Stryker notch view, taken Traumatic (macrotraumatic) with the patient supine and the hand placed on top of Atraumatic the head, shows the posterosuperior humeral head and Voluntary (muscular) Hill-Sachs lesions. CT scans can be helpful in selected Involuntary patients with complex bony injuries and in evaluation of Aquired (microtrauma) glenoid and humeral head version. Direction Unidirectional MRI has become a helpful tool to evaluate patients Anterior with acute and chronic shoulder instability. With MRI, Posterior capsular and ligament detachments, labral lesions, rota- Inferior tor cuff tears, and bony trauma can be identified with Bidirectional more accuracy than with radiographs or CT scan. Anterior-inferior Posterior-inferior Examination Under Anesthesia and Arthroscopy Multidirectional Although classification of the frequency, etiology, and (Reproduced with permission from Backer M, Warren RF: Glenohumeral instabilities in direction of instability may be evaluated with a thor- adults, in DeLee JC, Drez D Jr, Miller MD (eds): DeLee and Drez’s Orthopaedic Sports ough history and physical examination, the degree of in- Medicine: Principle’s and Practice. Philadelphia, PA, Saunders, 2003, pp 1020-1034.) stability is often best appreciated with examination un- der anesthesia or during arthroscopy. The axial load test of the shoulder girdle and upper extremity may reveal is used and the degree of instability in each direction is obvious deformity such as an acute dislocation. Anterior graded. dislocations are characterized by prominence of the hu- meral head anterior, medial, and often inferior to the Arthroscopic examination allows for complete as- shoulder joint, a hollow region beneath the lateral del- sessment of injured structures in the glenohumeral joint. toid, and the arm held in an abducted, slightly externally The articular surfaces, labrum, glenohumeral ligaments, rotated position. Posterior dislocations may be less obvi- integrity of the capsular tissue, biceps tendon, and rota- ous but a posterior prominence is usually noted and the tor cuff should be carefully inspected and probed. arm is held in an internally rotated and adducted posi- tion. The coracoid is prominent as well. More subtle Treatment of Acute Dislocation findings on inspection of a reduced but unstable joint include muscle atrophy caused by general neurologic Acute dislocations should be reduced as quickly and conditions, local nerve compression, and tendon tears. atraumatically as possible. After a trauma series is ob- tained, closed reduction is performed with the patient The strength of the muscles surrounding the shoul- relaxed with sedation or local anesthetics. der and the patient’s range of motion should be tested and compared with the contralateral side. The function A recent MRI study has shown that the conven- of the axillary nerve should be evaluated by testing the tional position of immobilization in adduction and inter- function of the deltoid and the sensation on the lateral nal rotation results in significantly more separation and aspect of the shoulder. displacement of a Bankart lesion than immobilization in adduction and external rotation. Provocative tests for shoulder instability allow the examiner to further classify the instability. Evaluation of In the young, highly active athletic population with a the contralateral side should be conducted for compari- traumatic anterior dislocation, primary surgical inter- son. Tests that reproduce the symptoms of instability in- vention may be warranted. Several studies from the US clude the apprehension test and the posterior load and Military Academy at West Point have reported recur- shift test. rent dislocation rates of 80% to 92% for cadets treated with physical therapy after initial traumatic shoulder dislocation. In this population, surgical intervention has 286 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 25 Shoulder Instability been advocated. In a recent prospective randomized clinical trial comparing arthroscopic stabilization with nonsurgical treatment of first-time shoulder dislocations in active duty soldiers, 75% of the nonsurgically treated patients developed recurrent instability, versus 11% of the arthroscopy treated patients. Average follow-up was 3 years. In another study from the US Military Academy at West Point, the recurrence rate of instability after pri- mary arthroscopic repair of initial anterior shoulder dis- locations at 2- to 5-year follow-up was 12%. Treatment of Recurrent Traumatic Instability Figure 4 A, In the normal shoulder, the capsule and labrum serve to deep glenoid. B, This effect is lost in the presence of a Bankart lesion. C, Anatomic repair restores Whereas the goal of rehabilitation is the enhancement effective depth of glenoid concavity. D, Nonanatomic repair does not restore normal of the dynamic stabilizers of the shoulder, the aim of “chock-block” effect of the capsulolabral structure. (Reproduced with permission from surgical intervention is the restoration of disrupted Matsen FA III, Lippitt SB, Sidles JB. Harryman DT II: Stability, in Matsen FA III (ed): static restraints. Primary stabilization should be consid- Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, ered for first-time traumatic shoulder dislocation with a 1994, p 59.) Bankart lesion confirmed by MRI in the athletic popu- lation younger than 25 years old. These patients have a older techniques for arthroscopic fixation, the recur- low rate of return to previous activity level if managed rence rate has been between 10% to 20%, approxi- with rehabilitation alone. In the older or less athletic mately twice as high as with open procedures. However, population, the primary indication for surgical stabiliza- in a recent review of the outcomes of 167 arthroscopic tion is recurrent instability despite an appropriate reha- Bankart repairs using suture anchor techniques, recur- bilitation program. rence of instability was 4% at a mean postoperative follow-up of 44 months with a mean loss of external ro- The goals for treatment of shoulder instability are tation of 2°. identical whether the procedure is arthroscopic or open. Anatomic repair of the static stabilizers involves identi- Recently there have been two prospective studies fication and reattachment of disrupted structures with comparing open procedures with arthroscopic stabiliza- minimal disturbance of the length and attachments of tion with biodegradable tacks for shoulder instability in uninvolved tissues (Figure 4). patients with Bankart lesions. In a prospective, random- ized multicenter study, 30 patients were treated with ar- An open Bankart repair involves an anterior ap- throscopic stabilization and 26 patients were treated proach to the glenohumeral joint and repair of the de- with an open procedure. At 2-year follow-up, the recur- tached capsulolabral structures to the glenoid through rence rate in the arthroscopic group was 23% versus drill holes or with suture anchors. With this time- 12% in the open group. In another study, which was not honored procedure, the expected success rate is approx- randomized, patients were evaluated at 3-year follow- imately 90% to 95%. Because the capsule is opened up. The patients in open and arthroscopic groups had during the approach and may be retensioned, imbri- similar demographics, although patients who underwent cated, or shifted, open repair is traditionally favored in open procedures had a greater number of dislocations situations of multiple recurrences with increased capsu- before surgery. In this study, the recurrence rate, includ- lar laxity. In addition, open repair is generally consid- ing subluxations or dislocations, was 15% in the arthro- ered a more durable procedure for patients who wish to scopic group compared with 10% in the open group. return to contact sports. The external rotation in abduction averaged 90° in the arthroscopic group compared with 80° in the open Arthroscopic stabilization techniques involve ana- group. tomic repairs without the takedown and reattachment of the subscapularis tendon as required in the open pro- cedure. The arthroscopic techniques have improved greatly. Fixation devices for reapproximation of the cap- sulolabral lesions have evolved from staples to transgle- noid sutures to cannulated bioabsorbable screws and su- ture anchors. In addition to shorter hospitalization times and less postoperative pain, results of arthroscopic pro- cedures show increased external rotation compared with open techniques. The major disadvantage of arthro- scopic techniques has been a higher recurrence rate in comparison with open procedures. In most studies using American Academy of Orthopaedic Surgeons 287

Shoulder Instability Orthopaedic Knowledge Update 8 Traumatic glenohumeral defects have been associ- ture anchor fixation. At a mean follow-up of 39 months, ated with failed Bankart repairs, particularly when per- 96% of these patients had a stable shoulder and were formed arthroscopically. Two bony lesions in particular, able to return to their prior sports activity with few or the engaging Hill-Sachs lesion and the inverted-pear no limitations. glenoid, have been associated with high rates of recur- rent instability after arthroscopic repair, particularly in Multidirectional Instability athletes who participate in contact sports. In the engag- ing Hill-Sachs lesion, the orientation of the Hill-Sachs There is a common misconception that multidirectional lesion is such that it engages the anterior glenoid in ab- instability is limited to young sedentary patients with duction and external rotation. In the inverted-pear gle- generalized ligamentous laxity, an atraumatic history, noid, the normal pear-shaped configuration of the gle- and bilateral symptoms. Although a subgroup of such noid is altered because of significant anteroinferior patients exists, shoulders with multidirectional instabil- bone loss, which creates an inverted pear appearance. ity are often seen in athletic patients, many of whom With these osseous findings, open procedures with re- have had an injury. Activities such as gymnastics or but- construction of the osseous defects may be warranted. terfly swimming may have resulted in repetitive mi- crotrauma that selectively stretched out the shoulders, Posterior Instability and other joints may not be lax on examination. Addi- tionally, Bankart lesions and humeral head impression Posterior instability occurs in 2% to 4% of patients with defects may be present in patients with multidirectional shoulder instability. Causative factors for posterior in- instability, although less commonly than in patients with stability include major trauma, repetitive microtrauma unidirectional traumatic instability. as in overhead athletes, and generalized ligamentous laxity. Acute posterior dislocations occur with load to a Symptoms typically include episodes of pain and in- flexed, adducted, and internally rotated upper arm and stability that are positional or occur after minimal force. are commonly missed at initial presentation. Patients The lesion in multidirectional instability was classically present with an adducted, internally rotated arm and thought to be a loose redundant inferior pouch with a are unable to externally rotate the shoulder. The classic large rotator interval. However, the etiology of multidi- radiographic findings on the AP view include a loss of rectional instability appears to be multifactorial and the humeral neck profile, a vacant glenoid sign, and an may include aberrant muscle firing patterns and abnor- anterior humeral head compression fracture (reverse mal connective tissue. In a recent MRI study, isometric Hill-Sachs lesion). After recognition, gentle reduction muscle activity leads to an off-centered humeral head should be performed with lateral traction, external rota- position in patients with multidirectional instability tion, and abduction. Initial treatment after radiographic compared with a recentered humeral head position dur- confirmation of reduction is immobilization in slight ex- ing muscle firing in patients with traumatic instability. tension and external rotation followed by physical ther- Initial treatment focuses on rehabilitation, which has apy. a greater than 80% success rate if sustained for 6 to 12 months. Most authors recommend a prolonged period of re- habilitation for symptoms of posterior instability. In pa- The goal of arthroscopic and open procedures is to tients who do not respond to nonsurgical treatment, a reduce the capsular volume of the joint while maintain- variety of surgical and arthroscopic interventions have ing motion. Capsular shift, performed anteriorly or pos- been described. Open procedures include posterior cap- teriorly, has an 85% to 90% success rate. Humeral- sulorrhaphy, bone block procedures, and glenoid or hu- based as well as glenoid-based shift procedures have meral osteotomy. One study reported results of open been described and have yielded similar success rates. posterior capsulorrhaphy for traumatic recurrent poste- rior subluxations in athletic patients; good or excellent Arthroscopic techniques include capsular plication, results were achieved in 13 of 14 patients. Arthroscopic rotator interval closure, and thermal capsular shrinkage. procedures include posterior capsular plication, thermal Various arthroscopic devices have been developed to shrinkage, and capsulolabral repair. In a recent retro- deliver heat to capsular tissue. Investigators have noted spective review of 27 shoulders treated with arthro- a 15% to 40% reduction in the length of collagenous tis- scopic repair using bioabsorbable tack fixation for a sue when it is heated to 65° to 72°C. This reduction in posterior capsulolabral detachment (posterior Bankart length has been shown to be caused by thermal denatur- lesion), symptoms of pain and posterior instability were ation of the collagen triple helix structure with subse- eliminated in 92% of patients at a mean follow-up of 5.1 quent reorganization into a random coil formation at a years. In another review of patients with traumatic uni- shorter length. A recent retrospective review of the re- lateral posterior instability, 27 patients with posterior sults of arthroscopic laser-assisted capsular shrinkage in Bankart lesions underwent arthroscopic repair using su- 27 shoulders with multidirectional instability has shown an overall success rate of 81.5% (with recurrent instabil- ity as a measure of failure) at an average follow-up of 288 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 25 Shoulder Instability 28 months. In another study using arthroscopic thermal Irreparable capsular deficiency after failed stabiliza- capsulorrhaphy to treat multidirectional instability in 30 tion procedures presents a particularly challenging situ- shoulders, 76% of patients had a good or excellent re- ation. Capsular deficiency has been described after open sult at an average follow-up of 3 years. The long-term procedures because of subscapsularis tendon incompe- sequela of thermal shrinkage techniques is not known. tence and after arthroscopic thermal capsulorrhaphy Recent studies of the behavior of lax ligaments treated caused by excessive thermal injury and tissue necrosis. with electrothermal shrinkage in animal models have Deficiencies of the subscapularis tendon can be recon- found that although thermal shrinkage reduced laxity, structed using a transfer of the sternal head of the pec- there was increased potential for creep and failure at toralis major tendon. Capsular deficiencies can be re- low physiologic stresses. A recent histologic analysis of constructed with a portion of the subscapularis tendon, the capsule from seven patients after failed thermal cap- autograft tissue, or allograft tendon. A recent report in sulorrhaphy showed denudation of the synovial layer which the iliotibial band was used to reconstruct the de- and morphologic changes in the collagen layer that ficient capsular tissues in seven patients showed the included, in some cases, a hyalinization appearance. elimination of instability and the maintenance of a phys- Although no pathognomonic histologic changes were iologic range of motion. identified, the study demonstrated that histologic abnor- malities may be present for years after failed thermal Osseous deficiency of the humerus or of the glenoid capsulorrhaphy. is a rare etiology of recurrent instability after failed sta- bilization. Bone procedures to reconstruct osseous defi- Failed Instability Surgery ciencies include the Latarjet and the Bristow procedures in which a portion of the coracoid is used to reconstruct Recurrent instability after surgical treatment of instabil- an inferior glenoid deficiency. Hill-Sachs lesions, an im- ity may occur because of new trauma, incomplete treat- paction fracture of the posterolateral margin of the hu- ment of pathologic lesions, poor rehabilitation, abnor- meral head, are found in more than 80% of patients mal host healing response, or diagnostic error. with traumatic anterior instability. These lesions are Treatment of recurrent stability after surgical stabiliza- thought to play a significant role in recurrent instability tion is difficult. Prior to surgical intervention, careful if they comprise more than 30% of the proximal hu- evaluation by history, physical examination, and diag- merus articular surface or if they engage the glenoid. nostic imaging should be performed to identify the Large Hill-Sachs lesions that engage the glenoid and cause of the recurrence. Recurrent instability after contribute to recurrent instability may be treated with failed stabilization should be classified according to di- osteochondral allografts. rection, degree, and frequency of instability. In patients with multiple failed stabilization proce- Initial treatment almost always consists of extensive dures and recurrent, debilitating instability, arthrodesis rehabilitation. New traumatic lesions may heal, and may be considered as a salvage procedure. A recent strengthening and improved control of the dynamic study evaluated the efficacy of shoulder arthrodesis per- muscular stabilizers may make the instability more tol- formed after an average of seven failed stabilization at- erable. tempts. The results of eight patients were reviewed at a mean follow-up of 35 months. All patients had achieved Surgical intervention should be directed by the etiol- bony union and all patients reported that they would re- ogy of the recurrent instability. Common findings at re- peat the surgery. vision surgery include excessive capsular redundancy, uncorrected Bankart lesions, and bone loss from the gle- Chronic Dislocations noid or from the humeral head. Incomplete correction of pathologic lesions, particularly Bankart lesions, The diagnosis of chronic locked anterior or posterior should be repaired anatomically. An inferior capsular shoulder dislocations may be made after physical exam- shift should be performed in patients with capsular lax- ination and proper radiographic analysis. Nonsurgical ity, particularly in those with a patulous axillary pouch. treatment may be considered in elderly patients with poor general mental status, especially when the condi- One retrospective review investigated the outcome tion is associated with limited pain. Surgical treatment is of 50 patients who underwent revision anterior stabiliza- necessary for reduction of the joint. Humeral head im- tion. Forty-nine of the procedures involved an open cap- paction fracture (Hill-Sachs lesions with chronic ante- sular shift, and 23 shoulders underwent concomitant re- rior dislocations and reverse Hill-Sachs lesions with pair of a Bankart lesion. At an average 4.7-year follow- chronic posterior dislocations) may preclude stable re- up, good or excellent results were obtained in 78% of duction. patients. The authors identified factors associated with poor results of the revision procedure that included atraumatic causes of failure, voluntary dislocations, and multiple prior stabilization attempts. American Academy of Orthopaedic Surgeons 289

Shoulder Instability Orthopaedic Knowledge Update 8 Figure 5 The Rockwood classification of ligamentous injuries to the acromioclavicular joint. Type I, no disruption of the acromioclavicular or coracoclavicular ligaments. Type II, disruption of the acromioclavicular ligament (coracoclavicular ligaments remain intact.) Type III, disruption of the acromioclavicular and coracoclavicular ligaments. Type IV, disruption of the acromioclavicular and coracoclavicular ligaments, and the distal end of the clavicle is displaced posteriorly into or through the trapezius muscle. Type V, disruption of the acromioclavicular and coracoclavicular ligaments, along with disruption of the muscle attachments and creation of a major separation between the clavicle and the acromion. Type VI, disruption of the acromioclavicular and coracoclavicular ligaments. Inferior dislocation of the distal clavicle in which the clavicle is inferior to the coracoid process and posterior to the biceps and coracobrachialis tendons. (Reproduced with permission from Rockwood CA, Williams GR, Young DC: Shoulder instability, in Rockwood CA, Green DP, Bucholz RN, Heckman JD (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, p 1354.) Acromioclavicular Separations past to help distinguish between type II and type III AC joint separation; however, this technique is no longer fa- The acromioclavicular (AC) joint is a sturdy structure vored because it usually does not influence the choice of that affixes the clavicle to the scapula. Injury to the AC treatment. joint is common (comprising approximately 9% of shoulder girdle injuries) and occurs most often in males Type I and II AC separations are considered incom- in their 20s. The AC joint is surrounded by and stabi- plete lesions and may be treated conservatively with ice, lized by a capsule and AC ligaments (superior, inferior, rest, and a brief period of immobilization followed by anterior, and posterior). Additional joint stability is pro- therapy. Types IV, V, and VI are complete injuries that vided by the coracoclavicular ligaments (trapezoid and usually require surgical reconstruction. Treatment of conoid) as well as the coracoacromial ligament. type III injuries remains controversial. Injury to the AC joint is understood as a sequential Sternoclavicular Dislocations loss of AC stabilizers. The classification of AC joint in- stability reflects this anatomic progression of injury The sternoclavicular joint is the only true articulation (Figure 5) and is useful in directing treatment. between the clavicle and the axial skeleton. Sternoclav- icular dislocations are usually the result of high-energy Radiographic evaluation of the AC joint may be per- force sustained during a motor vehicle accident or dur- formed with standard AP and lateral views of the shoul- ing contact sports activity. der. However, improved visualization of the AC joint is achieved with a Zanca view, performed by tilting the Classification of sternoclavicular dislocations is beam 10° to 15° cephalad. Additionally, only one third based on anatomic findings. Anterior dislocations are to one half of the penetration strength for a standard most common and are present when the medial end of AP of the glenohumeral joint is used to more precisely the clavicle is displaced anterior or anterosuperior to visualize the AC joint; standard shoulder radiographic the sternum. Patients with anterior dislocations have a penetration will overpenetrate the less dense AC joint. palpable medial clavicular head mass that may be more Stress views, using 5-lb weights placed on the wrist and pronounced with abduction and elevation. Posterior dis- comparing both AC joints, have been advocated in the locations are uncommon but more concerning. The me- 290 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 25 Shoulder Instability dial end of the clavicle is displaced posteriorly or postero- Twenty-one active duty military personnel between the superiorly and may impinge on vital structures. The ages of 18 and 26 years with primary, traumatic shoulder dislo- patient presents with a hollow region just lateral to the cation were randomized to nonsurgical treatment or arthro- sternum, and may also present with dyspnea or dysph- scopic Bankart repair using a bioabsorbable tack. At an aver- agia. age of 3 years follow-up, 75% of patients treated nonsurgically versus 11% of the patients treated with arthroscopic repair de- Radiographic evaluation involves standard chest ra- veloped recurrent instability. Six of nine patients treated non- diographs as well as the serendipity view obtained by di- surgically who developed recurrent instability required subse- recting the x-ray beam 40° cephalad to visualize both quent open Bankart repair. sternoclavicular joints. CT scan and/or MRI are cur- rently the best techniques to evaluate the sternoclavicu- Buss DD, Lynch GP, Meyer CP, Huber SM, Freehill MQ: lar joint and clearly distinguish the direction of the dis- Nonoperative management for in-season athletes with location as well as any associated fractures. In patients anterior shoulder instability. Am J Sports Med 2004;32: with posterior dislocation, CT and/or MRI allow for the 1430-1433. evaluation of mediastinal structures and visualization of the medial clavicular head in relationship to these struc- Thirty in-season athletes with either acute or recurrent an- tures. terior instability were treated with physical therapy and, if ap- propriate, bracing. Eighty-seven percent of athletes were able Acute reduction of anterior sternoclavicular disloca- to return to their sport in season and an average of 1.4 recur- tions may be attempted with traction of the extended rent instability episodes per season per athlete occurred. No arm. Residual anterior instability is well tolerated but further injuries were attributable to the shoulder instability. may result in persistent deformity. Posterior dislocations Fifty-three percent of patients had subsequent surgical stabili- should be reduced in the operating room with care zation in the off-season. taken to avoid damage to the mediastinal structures. Annotated Bibliography DeBerardino TM, Arciero RA, Taylor DC, et al: Pro- spective evaluation of arthroscopic stabilization of Pathophysiology acute, initial anterior shoulder dislocations in young ath- letes: Two- to five-year follow-up. Am J Sports Med Urayama M, Itoi E, Hatakeyama Y, Pradhan RL, Sato 2001;29:586-592. K: Function of the 3 portions of the inferior gleno- humeral ligament: A cadaveric study. J Shoulder Elbow Forty-eight cadets at the US Military Academy with 49 an- Surg 2001;10:589-594. terior dislocations were treated with primary arthroscopic re- pair using bioabsorbable tacks. At an average follow-up of 37 The strain of the three portions or sections of the inferior months, the average Rowe score was 92%, and 88% of shoul- glenohumeral ligament in 17 fresh-frozen cadaveric shoulders ders remained stable. Factors associated with failure included was studied during elevation and rotational maneuvers. The a history of bilateral shoulder instability, a 2+ sulcus sign, and anterior band and axillary pouch showed the greatest strain in poor capsulolabral tissue at the time of repair. All patients abduction and external rotation, confirming their role as ante- with stable shoulders returned to their preinjury levels of ath- rior stabilizers. The posterior band showed the greatest strain letic activity. These results are favorable compared with non- with flexion and internal rotation, suggesting a key role as a surgical treatment in young, active adults at the US Military posterior stabilizer. Academy. Urayama M, Itoi E, Sashi R, Minagawa H, Sato K: Cap- Itoi E, Hatakeyama Y, Kido T, et al: A new method of sular elongation in shoulders with recurrent anterior immobilization after traumatic anterior dislocation of dislocation: Quantitative assessment with magnetic reso- the shoulder: A preliminary study. J Shoulder Elbow nance arthrography. Am J Sports Med 2003;31:64-67. Surg 2003;12:413-415. Magnetic resonance arthrography was used to evaluate the Forty patients were randomly assigned to immobilization length of the anteroinferior, inferior, and posteroinferior cap- in external rotation versus immobilization in internal rotation sule in 12 patients with unilateral recurrent anterior instability. for 3 weeks after initial anterior dislocation. The average ages Unaffected shoulders were used as controls. The anteroinfe- in the internal and external groups were 38 years and 40 years, rior and inferior portions of the shoulder capsule were elon- respectively, with similar numbers of patients under the age of gated an average of 19% in shoulders with recurrent anterior 29 years. At approximately 1-year follow-up, the recurrence dislocation compared with the unaffected shoulders. rate was 30% in the internal rotation group and 0% in the ex- ternal rotation group. Anterior apprehension was positive in Treatment of Acute Dislocation 14% of the internal rotation group without recurrence and 5% of the external rotation group. Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective, randomized evaluation of arthroscopic sta- Miller SL, Cleeman E, Auerbach J, Flatow EL: Compar- bilization versus nonoperative treatment in patients ison of intra-articular lidocaine and intravenous seda- with acute, traumatic, first-time shoulder dislocations. Am J Sports Med 2002;30:576-580. American Academy of Orthopaedic Surgeons 291

Shoulder Instability Orthopaedic Knowledge Update 8 tion for reduction of shoulder dislocations: A random- (23%) at a mean of 13 months (range, 5 to 21 months) after ized, prospective study. J Bone Joint Surg Am 2002;84: surgery. In the open group, there were recurrences in 3 of 26 2135-2139. patients (12%) at a mean of 10 months (range, 2 to 23 months) after surgery (P = not significant). A tendency toward In a prospective study, 30 patients with anterior gleno- more redislocations in the arthroscopic group was noted. humeral dislocation were randomized to receive either intra- articular lidocaine or intravenous sedation before relocation Posterior Instability using the Stimson method. There was no significant difference between the two groups with regard to pain, success of the Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior Stimson technique, or time required for reduction of the labral and capsular shift for traumatic unidirectional re- shoulder. The lidocaine group spent significantly less time in current posterior subluxation of the shoulder. J Bone the emergency department and required less nursing re- Joint Surg Am 2003;85:1479-1487. sources. Twenty-seven patients with unidirectional posterior insta- Treatment of Recurrent Traumatic Instability bility were treated with arthroscopic labral repair and poste- rior capsular shift using suture anchors. At a mean postopera- Karlsson J, Magnusson L, Ejerhed L, Huttenheim I, tive follow-up of 39 months, all patients had a stable shoulder Lundin O, Kartus J: Comparison of open and arthro- by subjective and objective measurements except for one pa- scopic stabilization for recurrent shoulder dislocation in tient who had recurrent subluxation. Twenty-six patients re- patients with a Bankart lesion. Am J Sports Med 2001; turned to prior sports activity with few or no limitations. The 29:538-542. authors also describe arthroscopic findings in traumatic unidi- rectional recurrent posterior instability. One hundred eight shoulders with symptomatic, recurrent anterior instability and a Bankart lesion underwent either Williams RJ III, Strickland S, Cohen M, Altchek DW, open stabilization or arthroscopic stabilization with bioabsorb- Warren RF: Arthroscopic repair for traumatic posterior able tack fixation. At a mean follow-up of 28 months, the re- shoulder instability. Am J Sports Med 2003;31:203-209. currence rate, including both dislocations and subluxations, was 9 of 60 (15%) in the arthroscopic group, compared with Twenty-seven shoulders in 26 patients with traumatic pos- 5 of 48 (10%) in the open group. No significant differences terior shoulder instability were treated with arthroscopic re- were found between the study groups for the Rowe or Con- pair using bioabsorbable tack fixation. At a mean follow-up of stant scores at follow up. The only significant difference in 5.1 years, no patients showed a range-of-motion deficit. There range of motion assessment was in external rotation in abduc- was no instability greater than 1+ in the anterior, posterior, or tion, which was 90° (range, 50° to 135°) in the arthroscopic inferior directions. Symptoms of pain and instability were group and 80° (range, 25° to 115°) in the open group. The eliminated in 24 patients (92%). Two patients (8%) required treatment groups in this study were not randomized. additional surgery after arthroscopic repair of the posterior Bankart lesion. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I: Arthroscopic anterior stabilization of the shoulder: Two to six-year Multidirectional Instability follow up. J Bone Joint Surg Am 2003;85:1511-1517. Favorito PJ, Langenderfer MA, Colosimo AJ, Heidt RS One hundred sixty-seven patients with traumatic recurrent Jr, Carolonas RL: Arthroscopic laser-assisted capsular anterior instability were treated with arthroscopic Bankart re- shift in the treatment of patients with multidirectional pair using suture anchors. At a mean follow-up of 44 months, shoulder instability. Am J Sports Med 2002;30:322-328. the rate of postoperative recurrence of instability was 4% with a mean loss of external rotation of 2°. Postoperative recur- Twenty-seven shoulders in 25 patients with multidirec- rence was related to an osseous defect of more than 30% of tional shoulder instability were treated with an arthroscopic the glenoid circumference. These results compare favorably laser-assisted capsular shift procedure. At an average with historical results of open stabilization. follow-up of 28 months, 22 shoulders had no recurrent symp- toms and required no further surgical intervention. In five Sperber A, Hamberg P, Karlsson J, Sward L, Wredmark shoulders, treatment was considered a failure because of re- T: Comparison of an arthroscopic and an open proce- current pain or instability and the need for an open capsular dure for posttraumatic instability of the shoulder: A shift procedure. With recurrent instability as a measure of fail- prospective, randomized multicenter study. J Shoulder ure, the overall success rate was 81.5%. Elbow Surg 2001;10:105-108. Fitzgerald BT, Watson BT, Lapoint JM: The use of ther- Fifty-six patients with anterior instability and a Bankart le- mal capsulorrhaphy in the treatment of multidirectional sion were randomized to either open stabilization or arthro- instability. J Shoulder Elbow Surg 2002;11:108-113. scopic stabilization with the use of bioabsorbable tacks. Pa- tients were evaluated at 2, 12, and 24 months postoperatively. Thirty shoulders with multidirectional instability were Thirty patients were surgically treated with the arthroscopic treated with arthroscopic thermal capsulorrhaphy. At a mean technique and 26 patients with the open technique. In the ar- follow-up of 36 months (range, 24 to 40 months), 3 excellent, throscopic group, there were recurrences in 7 of 30 patients 20 good, and 7 poor results were reported using the University 292 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 25 Shoulder Instability of California, Los Angeles score. Twenty-three patients (76%) Eight patients with recurrent shoulder instability with an returned to full activity. average of seven prior stabilization attempts were treated with glenohumeral arthrodesis. The average time to bony union af- McFarland EG, Kim TK, Banchasuek P, McCarthy EF: ter arthrodesis was 3.5 months (range, 2.5 to 5 months). At Histologic evaluation of the shoulder capsule in normal mean follow-up of 35 months, the patients reported significant shoulders, unstable shoulders, and after failed thermal overall subjective improvement as a group after fusion. None capsulorrhaphy. Am J Sports Med 2002;30:636-642. of the patients reported instability postoperatively. All eight patients stated that they would repeat the surgery again under Shoulder capsules were evaluated histologically in 12 pa- similar preoperative circumstances. tients with traumatic anterior instability and in 7 patients who experienced recurrent instability after a thermal capsulorrha- Iannotti JP, Antoniou J, William GR, Ramsey ML: Ili- phy. The capsules of six fresh-frozen cadavers with no shoulder otibial band reconstruction for treatment of gleno- lesions were used as controls. In patients who had a history of humeral instability associated with irreparable capsular traumatic instability, a denuded synovial layer was present in deficiency. J Shoulder Elbow Surg 2002;11:618-623. 58%, subsynovial edema in 58%, increased cellularity in 25%, and increased vascularity in 83%. At the time of surgery, five Seven patients with recurrent anterior instability after of seven shoulders in the failed thermal capsulorrhaphy group failed surgery complicated by the loss of capsular tissue under- (71%) were subjectively felt to be thin and attenuated. De- went reconstruction of the capsular ligaments using the iliotib- nuded synovium was found in 100% of these patients, subsyn- ial band. After iliotibial band reconstruction, the patients ovial edema in 43%, and changes in the collagen layer in showed significant improvement in their American Shoulder 100%. Changes in the collagen layer in these patients included and Elbow Surgeons score (P =0.0004), and no patient had the appearance of hyalinization in five patients (71%), in- any persistent symptoms of instability. Physiologic range of creased collagen fibrosis in two patients (29%), and increased motion and function were maintained. The authors describe cellularity in two patients (29%). their surgical technique for iliotibial band reconstruction for capsular deficiency. von Eisenhart-Rothe RM, Jager A, Englmeier KH, Vogl TJ, Graichen H: Relevance of arm position and muscle Acromioclavicular Separations activity on three-dimensional glenohumeral translation in patients with traumatic and atraumatic shoulder in- Schlegel TF, Burks RT, Marcus RL, Dunn HK: A pro- stability. Am J Sports Med 2002;30:514-522. spective evaluation of untreated acute grade III acromi- oclavicular separations. Am J Sports Med 2001;29:699- Open MRI and three-dimensional post processing tech- 703. nique was used to evaluate glenohumeral translation with dif- ferent arm positions with and without muscle activation in 12 Twenty patients with acute grade III AC separations were patients with traumatic and 10 patients with atraumatic insta- treated nonsurgically with a sling for comfort through progres- bility. In patients with traumatic instability, increased transla- sive early range of motion as tolerated and completed a 1-year tion was observed only in functionally important arm posi- evaluation and strength-testing protocol. Subjectively, 4 of the tions, whereas intact active stabilizers showede sufficient 20 patients (20%) thought that their long-term outcome was recentering. In patients with atraumatic instability, a decentral- suboptimal, although 3 of them did not believe that the out- ized head position was recorded also during muscle activity, come should warrant surgery. Objective examination and suggesting alterations of the active stabilizers. strength testing of the 20 patients revealed no limitation of shoulder motion in the injured extremity and no difference Wallace AL, Hollinshead RM: FrankCB: Electrothermal between sides in rotational shoulder muscle strength. The shrinkage reduces laxity but alters creep behavior in a lap- bench press was the only strength test that showed a signifi- ine ligament model. J Shoulder Elbow Surg 2001;10:1-6. cant short-term difference, with the injured extremity being an average of 17% weaker. Using a lapine medial collateral ligament laxity model, the acute effects of radiofrequency shrinkage were assessed. Ther- Classic Bibliography mal treatment resulted in restoration of laxity but a significant increase in the cyclic and static creep strains compared with con- Bankart ASB: The pathology and treatment of recurrent trol sides. The authors concluded that radiofrequency electro- dislocation of the shoulder-joint. Br J Surg 1938;26:23- thermal shrinkage is effective at reducing laxity but significantly 29. alters viscoelastic properties, posing a risk of recurrent stretching-out at physiologic loads. Burkhart SS, DeBeer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Failed Instability Surgery Bankart repairs: Significance of the inverted-pear glenoid and humeral engaging Hill-Sachs lesion. Diaz JA, Cohen SB, Warren RF, Craig EV, Allen AA: Arthroscopy 2000;16:677-694. Arthrodesis as a salvage procedure for recurrent insta- bility of the shoulder. J Shoulder Elbow Surg 2003;12: 237-241. American Academy of Orthopaedic Surgeons 293

Shoulder Instability Orthopaedic Knowledge Update 8 Curl LA, Warren RF: Glenohumeral joint stability: Se- Thomas SC, Matsen FA III: An approach to the repair lective cutting studies on the static capsular restraints. of avulsion of the glenohumeral ligaments in the man- Clin Orthop 1996;330:54-65. agement of traumatic anterior glenohumeral instability. J Bone Joint Surg Am 1989;71:506-513. Hovelius L, Augustini BG, Fredin H, Johansson O, Nor- lin R, Thorling J: Primary anterior dislocation of the Tossy JD, Mead NC, Sigmon HM: Acromioclavicular shoulder in young patients: A ten-year prospective separations: Useful and practical classification for treat- study. J Bone Joint Surg Am 1996;78:1677-1684. ment. Clin Orthop 1963;28:111-119. Neer CS II, Foster CR: Inferior capsular shift for invol- Weaver JK, Dunn HK: treatment of acromioclavicular untary inferior and multidirectional instability of the injuries, especially complete acromioclavicular separa- shoulder: A preliminary report. J Bone Joint Surg Am tion. J Bone Joint Surg Am 1972;54:1187-1194. 1980;62:897-908. Wheeler JH, Ryan JB, Arciero RA, et al: Arthroscopic O’Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy versus nonsurgical treatment of acute shoulder disloca- and histology of the inferior glenohumeral ligament tions in young athletes. Arthroscopy 1989;5:213-217. complex of the shoulder. Am J Sports Med 1990;18:449- 456. Zabinski SJ, Calloway HG, Cohen S, Warren RF: Revision shoulder stabilization 2 to 10 year results. Rowe CR, Patel D, Southmayd WW: The Bankart proce- J Shoulder Elbow Surg 1999;8:58-65. dure: A long-term end-result study. J Bone Joint Surg Am 1978;60:1-16. Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF: Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 1994;76:1819- 1826. 294 American Academy of Orthopaedic Surgeons

Chapter 26 Shoulder Reconstruction Leesa M. Galatz, MD Rotator Cuff Tear tears. Histologic changes in chronic rotator cuff tissue tears have shown degenerative changes, but there is lit- Pathophysiology tle evidence of acute inflammation. This finding rein- forces the notion that changes in proteoglycan and The etiology of rotator cuff tears has not been clearly other extracellular matrix protein content in the aging elucidated. Focus has centered primarily on intrinsic and tendon may have a role in attritional changes leading to extrinsic mechanisms of generating rotator cuff tears, tears. More research is necessary to make definitive with reports in the early literature primarily focused on conclusions regarding the true etiology, and it is likely an extrinsic mechanism. Three types of acromial mor- that both intrinsic and extrinsic mechanisms as well as phology were defined (types I, II, and III), with increas- patient-related factors contribute to the development of ing curvature of each type. Type III acromions, with rotator cuff disease. maximal curvature or hooking of the undersurface, were associated with an increased incidence of rotator cuff After a rotator cuff is torn, several changes can tears resulting from increased mechanical contact of the occur in the shoulder joint. Clinically these changes cuff with the bone. Recent studies have provided data manifest as pain and decreased strength and range of that do not substantiate this early information and sug- motion. Radiographic changes can include proximal mi- gest a much more complex etiology for rotator cuff gration of the humeral head, narrowing of the acromial- tears. humeral interval, sclerosis of the undersurface of the ac- romion and superior humeral head, acetabularization or Attention has focused on the role and contribution rounding of the undersurface of the acromion such that of plain radiographic imaging for the diagnosis and de- it is congruent with the humeral head, and degenerative tection of full-thickness rotator cuff tears. Acromial os- changes of the glenohumeral joint. Most of these teophytes or spurring, acromioclavicular degeneration, changes occur only with massive, long-standing rotator and lateral clavicular and acromial sclerosis seen on cuff tears. These structural changes to the joint with ro- plain radiographs have been correlated with age rather tator cuff tears result from kinematic changes secondary than rotator cuff disease. Rotator cuff disease, especially to loss of the normal muscle forces about the shoulder. involving full-thickness tears, has also been correlated The purposes of the rotator cuff are to keep the hu- with age, complicating the issue. Although some cadav- meral head centered on the glenoid (termed concavity eric studies have demonstrated an association between compression) by counteracting the superior vector of spurring of the anterior acromion and the acromioclav- the deltoid, and to add strength and dynamic stability to icular joint and rotator cuff tears, a direct causal rela- glenohumeral motion. tionship between degenerative radiographic changes and full-thickness tears has not been definitively Several recent basic science studies have been per- proven. One recent study of radiographic changes in 40 formed to investigate the changes in forces and motion patients with full-thickness cuff tears and a large group patterns associated with rotator cuff tears. One cadav- of age-matched controls found no association between eric study examined the effect of rotator cuff tears on acromial morphology and rotator cuff tears. Findings joint reaction forces at the glenohumeral joint. There that were indicative of cuff tears included sclerosis, os- were no significant differences in joint reaction force teophytes, subchondral cysts, and osteolysis of the magnitude or direction with abduction motion between greater tuberosity. There was no relationship between the intact state, partial supraspinatus tear, or complete any of these findings in the greater tuberosity and tear supraspinatus tear. Extension of tears beyond the su- size. praspinatus tendon resulted in a significant decrease in the magnitude of the joint reaction force. Additionally, Intrinsic mechanisms of rotator cuff degeneration the vector of the force changed direction toward the de- have been implicated in the etiology of rotator cuff American Academy of Orthopaedic Surgeons 295

Shoulder Reconstruction Orthopaedic Knowledge Update 8 ficient area. Clinically, this finding may explain why Examination should begin with an inspection of both some patients with fairly large tears may still maintain shoulders to detect asymmetry or muscle atrophy. The function. The critical tear size at which the force couple examiner should stand behind the patient and observe of the remaining musculature is overcome and pseu- the scapulae during overhead elevation for winging and doparalysis of the shoulder results is yet to be deter- motion pattern. Range of motion should be recorded mined, and clinically seems to differ between individu- for elevation in the scapular plane, external rotation at als. the side, and external rotation in abduction to fully ex- amine the anterior capsule. Internal rotation can be Another cadaveric study was performed to compare tested by internal rotation of the shoulder with the arm the effects of supraspinatus detachments, tendon de- in 90° of abduction and by asking the patient to reach fects, and muscle retraction. Simply detaching a portion behind the back. Side-to-side comparison is critical to of the supraspinatus tendon had no effect on the force determine normal motion, as range of motion differs be- transmitted by the rotator cuff. Detaching or creating a tween individuals. defect of the entire supraspinatus tendon led to a mod- erate decrease in force transmission (11% and 17%, re- Supraspinatus strength is tested by external rotation spectively). However, when the investigators simulated with the arm at the side with the shoulder in neutral or muscle retraction of the tendon by incising medially to slight internal rotation. Testing external rotation with detach the tendon from adjacent tendon tissue, there the shoulder in external rotation allows substitution by were substantial reductions in force transmission (58% the posterior deltoid. Placing the arm in 90° of abduc- with involvement of the entire supraspinatus). Side-to- tion in the scapular plane with the thumbs down and side repair of smaller defects restored force capability, asking the patient to resist downward pressure is an- but a deficit remained even after side-to-side repair of other way to isolate the supraspinatus. This test (Jobe’s) the entire supraspinatus tendon retraction simulation. is useful for both strength and pain. A lag sign (for test- This study supports the cable concept of force transmis- ing the posterosuperior rotator cuff) is performed by sion of the rotator cuff, and suggests that the amount of placing the arm in maximal external rotation. A patient retraction and not just transverse diameter may be an with a large or massive tear will not be able to maintain important factor in functional deficit after a rotator cuff the arm in this position and the hand will swing toward tear. neutral rotation. In a patient with a massive tear, includ- ing the teres minor, the hornblower’s sign will be posi- Natural History tive (the patient is unable to externally rotate the arm to 90° with the arm in abduction). Positive results from The severity of rotator cuff disease ranges from painful these two tests are usually associated with massive tears cuffs without tears to partial-thickness tears to full- and there is correlation with fatty degeneration of the thickness tear. It is not known whether this is a continu- cuff musculature. ous spectrum in which a patient will go from one stage to the next as part of the natural history of their condi- Subscapularis integrity is tested using the lift-off test tion or whether some patients present at one stage, and the abdominal compression test. The lift-off test in- never progressing to another. One longitudinal ultra- volves placing the arm behind the back, at the midline, sonographic study showed that over a time period of at waist level. The patient is asked to raise the hand off 5 years, approximately 28% of patients had an increase the back, a motion requiring an intact subscapularis. An in size of known full-thickness rotator cuff tears. Addi- abdominal compression test is performed by placing the tionally, more recent data show a high prevalence of hand flat on the abdomen with a straight line between full-thickness tears in the opposite shoulders of patients the hand, wrist, and elbow. A patient with a torn sub- with full-thickness tears, and this was also seen more of- scapularis will either bend the wrist to keep the hand on ten as patients get older. Research on the natural his- the abdomen or lose contact. Internal strength can be tory of tears is ongoing and more information will likely tested in this position as well. be available in the near future. The Neer and Hawkins impingement signs are used Evaluation to detect pain related to rotator cuff disease by provok- ing impingement in the subacromial space by internally History and Examination rotating the shoulder, bringing the greater tuberosity Patients with rotator cuff tears report a history of shoul- underneath the acromion, and minimizing space avail- der pain and/or weakness. Pain associated with rotator able for the cuff. A thorough examination should also cuff tears is usually located on the anterolateral aspect include evaluation of the acromioclavicular joint for of the shoulder and often radiates distally toward the pain on direct palpation and pain with cross-body ad- deltoid insertion. Pain that radiates below the elbow to duction. Biceps tendon pathology is often associated the hand should raise suspicion of cervical radiculopa- with rotator cuff tears. The Speed and Yergason tests are thy or peripheral nerve compression. sensitive for biceps tendon pain. 296 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 26 Shoulder Reconstruction Diagnostic Studies clude the following: (1) tears are easier to repair when Plain radiographs should be the initial radiographic they are smaller, and there is documented evidence that study of choice. A standard series should include an AP tear size can increase with time; (2) there is a higher re- radiograph of the shoulder with the arm in internal ro- currence rate after repair of large and massive tears; tation, an AP radiograph of the scapula with the arm in (3) long-standing chronic tears are associated with muscle neutral or slight external rotation, an outlet view, and an atrophy and fatty degeneration, which are irreversible axillary view. The acromioclavicular joint is best visual- changes that can compromise functional outcome after re- ized on the AP view of the shoulder. The glenohumeral pair; and (4) there may be attritional changes in the ten- joint space is assessed on the scapular AP and the axil- don edge of chronic tears that may compromise healing lary views, in which degenerative changes are best de- potential. tected. The outlet view enables evaluation of acromial morphology. MRI is valuable for evaluating the soft tis- Surgical Approaches sues about the shoulder and is a sensitive and specific An open surgical approach involves an incision and re- test for rotator cuff pathology. The role of ultrasonogra- moval of the anterior deltoid origin from the acromion phy in the evaluation of the rotator cuff has gained pop- to maximize exposure. The major advantage of an open ularity in recent years because it is highly accurate in repair is the extensive exposure and ability to mobilize making the diagnosis of full-thickness and partial- the cuff under direct observation. It also requires no ar- thickness tears. Because the reliability of ultrasonogra- throscopic skills. A mini-open repair is alternatively per- phy is operator-dependent, significant experience should formed through a deltoid split rather than removing the be gained before this study is used independently. MRI deltoid origin. To achieve a repair using a mini-open ap- has largely replaced arthrography, which is rarely used; proach, arthroscopic assistance is used. Because expo- however, arthrography remains a good alternative if an sure is more limited, inspection, cuff mobilization, and MRI evaluation cannot be obtained and an ultrasound the acromioplasty are performed with the use of the ar- is not available. throscope, obviating the need for a more extensile ap- proach. The major advantage of a mini-open repair is Treatment of Partial-Thickness Rotator Cuff Tears that the deltoid is not removed from the acromion. Re- moval of the deltoid is one of the more painful aspects Partial-thickness tears are often managed successfully of the open procedure, and failure of the deltoid repair with nonsurgical treatment. An exercise program fo- is a serious and painful complication for which there is cuses on range of motion, stretching, and strengthening no reliable option for correction. of the rotator cuff, deltoid, and scapular stabilizers. Partial-thickness tears that do not become asymptom- Arthroscopic repair of full-thickness tears has gained atic with nonsurgical treatment can be effectively recent popularity. As equipment and techniques con- treated surgically. Arthroscopic treatment entails débri- tinue to advance, this approach will likely continue to dement of the tear after careful inspection of both the become easier and more achievable with advanced ar- articular and bursal sides. In general, if the tear involves throscopic skills. Potential advantages of an arthroscopic less than 50% of the thickness of the cuff, débridement approach include decreased scarring, easier rehabilita- should be adequate. If the tear involves more than 50% tion, decreased pain, and improved cosmesis. Damage to of the thickness of the cuff or the remaining tissue is de- the deltoid is minimized with an arthroscopic approach. generative and easily débrided, then the tear is ex- One disadvantage to an arthroscopic repair may be a panded to a full-thickness tear and healthy tissue is re- higher recurrence rate after repair of large and massive paired primarily. Recently, several arthroscopic methods tears. The procedure requires advanced arthroscopic of imbricating partial-thickness tears and repairing lami- skills, which may be considered by some to be a disad- nated flaps have been described, and offer promising vantage of using the procedure; however, the use of options in the management of partial-thickness tears. minimally invasive approaches is becoming mainstream. Treatment of Full-Thickness Rotator Cuff Tears Role of Acromioplasty An acromioplasty has historically been a standard as- Nonsurgical treatment for full-thickness tears is the same pect of a rotator cuff repair based on Neer’s classic de- as for partial-thickness tears in terms of exercise and pain scription of impingement syndrome and the theory that control measures. Surgical treatment of symptomatic full- contact with the rigid coracoacromial arch is the me- thickness rotator cuff tears is indicated in patients in chanical impetus for rotator cuff tears. An acromio- whom nonsurgical treatment has failed and who are can- plasty entails takedown of the coracoacromial ligament didates for surgery, those with acute tears, and patients from the anterior acromion and removal of bone from with tears associated with a sudden loss of strength and the undersurface of the acromion to increase the space function. Relative indications include younger people of available for the rotator cuff. Historically, removal of working age with a painful tear. Factors to consider in- large amounts of bone, including full-thickness removal American Academy of Orthopaedic Surgeons 297

Shoulder Reconstruction Orthopaedic Knowledge Update 8 Figure 1 A, Radiograph of a shoulder after failed rotator cuff repair and distal clavicle resection. The anchors have failed, the humeral head has migrated anteriorly and superiorly, and degenerative changes have begun to involve the glenohumeral joint. B, MRI of the shoulder demonstrates the massive rotator cuff tear and proximal migration. C, A sagittal oblique cut of the MRI demonstrates the cuff insufficiency as well as the deltoid attenuation. of bone from the anterior acromion in some instances, series of tears involving the subscapularis, a lower Con- was recommended. The more recent trend for acromio- stant score correlated with duration of symptoms longer plasty is to remove enough bone to make the undersur- than 6 months and the appearance of fatty degeneration face of the acromion flat to protect the origin of the del- and atrophy of the subscapularis muscle as detected by toid. One anatomic study found that the average MRI. The authors recommended repair of the subscapu- thickness of the acromion was 7 mm. Therefore, removal laris before 6 months of symptoms to maximize func- of large amounts of bone, as had been previously rec- tional outcome. ommended, could potentially compromise the acromion and deltoid origin. Complications Results of Treatment The rate of complications after rotator cuff repair is low Rotator cuff repair has historically been a reliable op- in most series. Potential complications include stiffness, tion for pain relief over time. This finding has been sub- infection, deltoid dehiscence after open repair, failure of stantiated by two long-term follow-up studies. In a re- repair, and less commonly, neurovascular injury. Al- cent study, results of a large number of patients treated though the incidence of infection is low after rotator with open cuff repair, V-Y plasty, tendon transposition, cuff repair, recently one organism, Propionibacterium and reinforcement with fascia lata were reported. Tear acnes, has gained attention as a frequent cause of infec- size was the most important determinant of outcome tion in the shoulder. This is a low virulence organism with regard to active motion, strength, rating of the re- that was found in the few infections in a large series of sult, patient satisfaction, and need for another opera- mini-open rotator cuff repairs. tion. Another recent study reported over 90% good to excellent results in a prospective series of patients after Another complication that has become increasingly open cuff repair on the shoulder. These patients were recognized is anterior-superior instability in the shoul- studied longitudinally over a 10-year period. Outcome der associated with massive, irreparable cuff tears. This at 10 years had not deteriorated from the 2-year results, complication results from a combination of rotator cuff demonstrating the longevity of results after rotator cuff insufficiency, disruption of the coracoacromial arch, and repair. anterior deltoid dehiscence. Anterior-superior instability usually is an iatrogenic complication after open cuff re- One recent study showed 46 of 48 good to excellent pair and subacromial decompression where the deltoid results after arthroscopic repair of medium to large full- and rotator cuff repair have failed (Figure 1). Clinically, thickness rotator cuff repairs. Forty-four of 45 patients it is recognized by proximal and anterior migration of were satisfied with the results. Another study reported the humeral head to the subcutaneous position and obli- on the results of arthroscopic rotator cuff repair of large gates extension of the shoulder with attempted over- and massive chronic tears. Despite a high rate of satis- head elevation. This condition occurs because the intact faction and significantly improved functional outcome, posterior and lateral deltoid exert a superior vector on ultrasonographic analysis revealed 17 of 18 patients had the humerus, with no rotator cuff or coracoacromial recurrent tears. These results suggest that success in arch to keep the head contained. Surgical attempts at terms of functional outcome and pain relief may not coracoacromial arch reconstruction and muscle transfers correlate with anatomic healing of the rotator cuff. In a for treatment of this problem have met with unpredict- able results and limited success. 298 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 26 Shoulder Reconstruction Treatment of the Massive Rotator Cuff Tear Figure 2 An MRI of a massive cuff tear. The cuff has retracted to the level of the superior glenoid rim. The muscle belly has undergone severe atrophic changes and a Treatment of the massive rotator cuff tear is a contro- widened subtrapezial fat space (arrow) is evident. There is also proximal migration of versial issue. It is important to consider that the massive the humeral head relative to the glenoid. tear does not equal the irreparable tear. Many massive tears are easily repairable, and some smaller tears and a significant improvement in functional outcome and many massive tears can be irreparable. Preoperative pain relief, and a high degree of patient satisfaction de- evaluation of the massive tear should give some indica- spite a high recurrence rate. The margin convergence tion as to the likelihood of successful repair. MRI dem- technique has been used in patients undergoing arthro- onstrating significant atrophy and fatty degeneration of scopic repair of massive tears, with an improvement in the musculature (Figure 2) along with a history consis- range of motion and high degree of patient satisfaction. tent with a chronic tear can indicate a difficult if not im- One recent study reported on the results of tubero- possible repair. Most studies that have examined the an- plasty, a procedure in which the bony excrescences of atomic results after rotator cuff repair have the greater tuberosity are débrided such that the hu- demonstrated a higher rate of recurrence with larger meral head conforms to the rounded undersurface of tears. Therefore, preoperative discussions with patients the acromion. No subacromial decompression was per- should include a discussion of these results as well as formed in this series. Although the long-term results of patient goals and expectations after surgery. Overall, re- arthroscopic treatment in patients with massive tears pair of a massive tear can be potentially predictable for are not yet available, early results suggest that it can pain relief, but it is much less reliable for restoring lost play a role in the management of this challenging prob- strength. lem. A repair should be performed if possible. The role of an acromioplasty alone in the treatment of a massive Nonsurgical treatment should be attempted initially, rotator cuff tear remains debatable, but it is clear that especially in the older patient with lower physical de- excessive bone removal along with compromise of the mands. Younger patients of working age in whom anterior deltoid leads to significantly inferior results and strength is more important are exceptions; early inter- is therefore contraindicated. If an acromioplasty is per- vention should be considered in these patients to avoid formed, an arthroscopic approach and conservative future irreversible, degenerative changes that compro- bone removal, if any, are recommended. mise results. Physical therapy helps to strengthen the re- maining musculature about the shoulder and improve The final option for treatment of a massive rotator kinematics to facilitate or regain range of motion. Non- cuff tear is a muscle transfer. A transfer of the pectoralis steroidal anti-inflammatory drugs and cortisone injec- major is performed for a chronic irreparable subscapu- tions are options for providing pain relief. laris tear, and a latissimus transfer is used for posterior and superior cuff insufficiency. Other transfers have Surgical treatment options include open or mini- been described, but results are not as favorable and they open repair, débridement, and arthroscopic repair. Most are rarely used today. Indications for a latissimus trans- studies of open and mini-open repair have found that an fer for an irreparable tear involving supraspinatus, in- increasing tear size correlates with inferior results. Sim- fraspinatus, and teres minor tears are primarily pain and ple débridement and acromioplasty have been advo- loss of function. Relative indications are a young, active cated, especially for irreparable tears, with a reported 83% satisfaction rate for this procedure at an average 6.5-year follow-up. In other studies, it was shown that the results of treatment with débridement were inferior to results in a series in which the cuffs were repaired. Results of débridement deteriorated with time, and a comparison of results of débridement with those of open repair found that patients who had open repair had better strength, function, and outcome scores, al- though patient satisfaction was comparable. Arthroscopic treatment is particularly advantageous in the management of massive rotator cuff tears because it allows assessment of whether the tear is repairable before an open incision and splitting or detaching of the deltoid is performed. An intact deltoid is critical for a good result in a patient with a massive tear, whether or not it is repaired. Limited, early results of arthroscopic repair are promising. In a previously mentioned study of arthroscopic repair of large and massive tears, there was American Academy of Orthopaedic Surgeons 299

Shoulder Reconstruction Orthopaedic Knowledge Update 8 patient and an intact subscapularis. Inferior results are Glenohumeral Joint Arthritis reported for patients with concurrent subscapularis tears. The deltoid must also be intact and functioning Etiology well. A muscle transfer is a major reconstructive proce- dure with a long period of rehabilitation, and should Glenohumeral joint arthritis results from multiple dif- only be considered as a salvage operation for patients ferent etiologies, including primary osteoarthritis, the willing and able to undergo the operation and comply synovial-based arthroses such as rheumatoid arthritis, with the rehabilitative program. osteonecrosis, posttraumatic arthritis, malunion or non- union of the proximal humerus, rotator cuff arthropathy, Role of the Biceps Tendon and arthritis associated with instability or surgery for in- stability. The etiology of shoulder arthritis is important The role of the long head of the biceps tendon contin- because each of these entities is associated with certain ues to generate interest and controversy. Its exact func- characteristics that impact the technique and/or out- tion, if any, in the shoulder is a subject of debate with come of the surgery. both cadaveric and clinical studies that support several differing viewpoints. Nevertheless, the long head of the Primary osteoarthritis is associated with osteophyte biceps tendon is an increasingly recognized source of formation and posterior glenoid wear. Posterior wear pain in the shoulder in conjunction with rotator cuff pa- can make glenoid implantation very challenging and at thology. The synovial lining of the glenohumeral joint is times can even preclude glenoid insertion. One solution continuous with the tenosynovium of the proximal bi- to this problem is bone grafting the glenoid with inter- ceps so any inflammatory process involving the joint can nally fixed corticocancellous bone. A recent report on affect the biceps tendon as well. this procedure in 21 shoulders with an average correc- tion of 33° demonstrated that this is a technically de- The biceps tendon should be carefully inspected dur- manding procedure with failure in eight patients. Rheu- ing any rotator cuff repair to rule out any concurrent pa- matoid arthritis, on the other hand, can be associated thology. This evaluation is generally performed as part of with osteophyte formation but more typically presents the arthroscopic assessment.The portion of the biceps ten- with central wear of the glenoid, osteopenia, bone ero- don from the intertubercular groove should be pulled into sions, and subchondral cyst formation. the joint for inspection as well. Lesions of the tendon can include inflammation of the tendon, tearing, or instability Arthritis secondary to previous instability surgery is relative to the intertubercular groove. Instability is always thought to arise because of an imbalance in the soft tis- associated with subscapularis tears or tears of the rotator sues surrounding the shoulder. This condition most often interval. In some circumstances, the tendon may have al- occurs after older instability procedures that involved ready ruptured. This condition is more common in con- transfer or imbrication of the subscapularis have been junction with larger tears. done, leaving the shoulder extremely deficient in exter- nal rotation. These shoulders also have large osteophyte Minor fraying involving only a minimal amount of formation and preferential posterior glenoid wear. The the tendon proper can be débrided; however, a tear in- soft-tissue contractures and scarring about the shoulder volving 50% or more of the tendon should be treated make the approach and exposure for shoulder arthro- with tenotomy or tenodesis. Any instability of the ten- plasty extremely difficult. Static posterior subluxation of don should also be treated in this fashion. The issue of the humeral head has recently been recognized as a pos- whether to use tenotomy or tenodesis of the long head sible etiology of early glenohumeral arthritis in young of the biceps tendon is also a subject of debate. In gen- adults. One recent article discussing a small group of eral, tenodesis is indicated in younger patients (younger men (average age, 40 years) with early arthritis found an than 55 years) because of concerns about muscle cramp- increase in mean glenoid retroversion and marked static ing and cosmesis. Potential disadvantages are increased posterior subluxation. The condition was unresponsive to length of the procedure, possible pain at the tenodesis surgical treatment, and could indicate a risk for the de- site, and the possibility of an additional incision. Older velopment of glenohumeral arthritis in some patients. patients have done well with simple tenotomy, with little to no noticeable deformity, but it is important to discuss Arthroplasty after nonunion or malunion of the the possibility of either procedure with patients preop- proximal humerus is another very difficult problem to eratively. manage. The outcome is better if the reconstruction does not involve osteotomy of the tuberosities. There- Recently, biceps tenotomy has been performed as fore, every effort should be made to accommodate the part of the surgical procedure for massive rotator cuff abnormal bony anatomy with a modular prosthesis (Fig- tears. In one series containing the largest number of pa- ure 3). Osteonecrosis is characterized by sclerosis early, tients treated with tenotomy for rotator cuff tears, teno- bone collapse at the later stages, and degenerative tomy was found to be particularly effective for massive changes on both the glenoid and humeral sides at the tears. last stage. Stiffness is often a prominent characteristic of arthritis associated with osteonecrosis. 300 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 26 Shoulder Reconstruction Figure 3 A, A healed proximal humerus fracture has left the surgical neck with a varus malunion. The glenohumeral joint shows evidence of posttraumatic arthritis. B, A prosthesis has been placed without osteotomy of the surgical neck or greater tuberosity. Modularity of the prosthesis facilitates an attempt to recreate normal anatomy. Surgical Treatment tors that made hemiarthroplasty advantageous over to- tal shoulder replacement were shorter operating room Indications and Contraindications time and less blood loss. Another study of the long-term The main indication for shoulder arthroplasty is end- follow-up of both procedures cited the 15-year survival stage arthritis associated with pain unresponsive to non- rate as 93% for the patients who had total shoulder ar- surgical measures. Contraindications include active in- throplasty and 75% for the patients who underwent fection, absence of both deltoid and rotator cuff hemiarthroplasty. musculature, neuropathic arthropathy such as a Charcot joint, and intractable instability. Relative contraindica- Results of conversion of a hemiarthroplasty to a to- tions to glenoid implantation include young patients, ex- tal shoulder arthroplasty at a later date has not proved cessive bone loss from the glenoid, and rotator cuff ar- to be as satisfactory as originally thought. There is often thropathy. severe bone loss on the glenoid side after a hemiarthro- plasty, which makes glenoid implantation more chal- Prosthetic Arthroplasty: Hemiarthroplasty Versus Total lenging (Figure 4). Pain relief in this group of patients is Shoulder Arthroplasty not as predictable; additional surgery is often required. Prosthetic replacement for primary osteoarthritis has In one series of 18 conversions, there was marked pain historically been associated with extremely favorable re- relief and increased range of motion; however, results sults. Whether to use hemiarthroplasty or total shoulder were unsatisfactory in 7 because of limited motion and arthroplasty remains a topic of debate. Advantages cited additional surgery. Overall, although some controversy for performing a hemiarthroplasty include less lateral- still exists, total shoulder replacement including implan- ization of the joint line, less time spent in the operating tation of a glenoid component is emerging as the stan- room, less blood loss, easier procedure, and the fact that dard for the treatment of primary osteoarthritis. conversion to total shoulder arthroplasty can be per- formed at a later date. Advantages of glenoid implanta- It is well established in the literature that pain relief tion include better pain relief and longer survival of the is much better with total shoulder arthroplasty for rheu- arthroplasty. Various authors have reported good results matoid arthritis. A recent study of 105 shoulder arthro- using both techniques. Most of the recent literature plasties in patients with rheumatoid arthritis showed no however, supports the use of glenoid components be- statistical difference in Constant score between humeral cause the results are better for pain relief in long-term head replacement and total shoulder arthroplasty. The follow-up. One prospective, randomized study showed group that underwent total shoulder arthroplasty had a superior results in the total shoulder group, with a 12% high rate of glenoid lucencies (58%), but none required revision rate in the hemiarthroplasty group at an aver- revision, demonstrating excellent longevity of the gle- age follow-up of 35 months. In this study, the only fac- noid in this population. Of significance, in the group that had humeral head replacement, there was superior American Academy of Orthopaedic Surgeons 301

Shoulder Reconstruction Orthopaedic Knowledge Update 8 Figure 4 A, A hemiarthroplasty was placed for osteoarthritis in this patient, without relief of pain. The head is slightly proud and asymmetric glenoid wear has occurred such that the center of the glenoid is worn to the base of the coracoid. B, The hemiarthroplasty was converted to a total shoulder arthroplasty. A pegged glenoid component was inserted to restore joint space and help lateralize the joint line to a more anatomic location. migration of the humeral component by more than tator cuff arthropathy has historically been discouraged 5 mm in 28% and medial migration by more than 2 mm because of concerns over early loosening. Earlier rec- in 16%. This migration did adversely affect the outcome ommendations were to oversize the humeral head in in these patients. Overall, the 8-year survival rate was these shoulders. The technique of humeral head replac- 92% in this population. The issue of bone wear in rheu- ment has evolved, however, and anatomic head sizing is matoid arthritis remains a critical complication in terms now advised. Overstuffing the joint has been associated of potential reconstruction. Rheumatoid shoulders tend with painful arthroplasty because of soft-tissue stretch. to have central wear of the glenoid, which can eventu- This overstuffing also lateralizes the deltoid insertion, ally preclude implantation of a prosthetic component. compromising its function. Preservation of the coracoac- Therefore, at this point, the standard of care is to per- romial arch is critical during humeral head replacement form a total shoulder arthroplasty in a rheumatoid for rotator cuff arthropathy to prevent anterior-superior shoulder unless severe bone wear already makes this instability. Bipolar components have not demonstrated impossible. improved results in these cases and are rarely used. Re- verse ball and socket prostheses are still under investi- When osteonecrosis is diagnosed at an early stage gation and may hold promise for future use in treating before the development of degenerative changes on the rotator cuff arthropathy. glenoid, the results of hemiarthroplasty have been con- sistently favorable. In patients with long-standing dis- Total Shoulder Arthroplasty ease with radiographic involvement of the glenoid or in Total shoulder arthroplasty is a reliable operation for patients in whom cartilage wear is discovered at the pain relief and good function can be anticipated. Re- time of surgery, total shoulder arthroplasty is recom- cently, a large study reported the results of arthroplasty mended. for osteoarthritis using a third generation, anatomically designed shoulder prosthesis. Patients were evaluated Glenoid implantation is generally not recommended using the age-adjusted Constant score an average of in patients with rotator cuff arthropathy. These shoul- 30 months postoperatively. The score improved from an ders are characterized by severe degenerative changes average of 37 to 97 postoperatively. Good or excellent to the glenohumeral joint, with complete loss of the results were obtained in 77% of patients, and 94% were joint space in combination with a massive rotator cuff satisfied or very satisfied. Forward elevation was 145°. tear with subsequent loss of rotator cuff function, result- ing in proximal migration of the humeral head such that Another recent study investigated the effect of rota- it articulates with the undersurface of the acromion. tor cuff disease on the outcome of total shoulder arthro- There also is often a slight anterior superior sublux- plasty. Rotator cuff tears are uncommon in patients with ation. Glenoid implantation during arthroplasty for ro- 302 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 26 Shoulder Reconstruction osteoarthritis, occurring in less than 5%. In this series of bone grafting of the defects; these patients may be can- 514 patients, 41 had a partial-thickness tear and 42 had a didates for glenoid component placement after graft full-thickness tear. Supraspinatus tears did not adversely consolidation. affect outcome, satisfaction, or mobility. Treatment of the tears did not change outcome parameters. However, Nonprosthetic Treatment Options for Glenohumeral shoulders with moderate or severe fatty degeneration of Arthritis The role of arthroscopy in the treatment of the infraspinatus were associated with poorer results. glenohumeral joint arthritis remains unknown and re- This study suggests that small tears limited to the su- cent studies of results in the knee joint have made this a praspinatus do not negatively affect the outcome; how- controversial topic. Nevertheless, there are several re- ever, more global degenerative changes in the rotator cent reports of small studies of arthroscopic treatment cuff musculature will. of arthritis in the shoulder suggesting favorable short- term results. Indications for arthroscopic surgery for ar- Another prospective study further substantiates the thritis are ill defined, but generally include younger pa- fact that small tears of the supraspinatus do not ad- tients in whom it is desirable to prolong the need for versely affect the outcome after total shoulder arthro- prosthetic arthroplasty, and those with concentric wear plasty. This study was performed to determine the effect of the glenoid, absence of severe joint contracture, loose of tears, preoperative glenoid bone erosion, and radio- bodies, and minimal if any bone loss. Arthroscopic treat- graphic evidence of subluxation of the humeral head on ment is most useful in alleviating mechanical symptoms the outcome of shoulder arthroplasty. Tears of the su- from loose cartilage fragments or interposed soft tissue. praspinatus tendon did not adversely affect the out- Contraindications to arthroscopy for the treatment of come. Radiographic posterior subluxation of the hu- arthritis include older patients with global arthritis who meral head was associated with a lower outcome score, are candidates for shoulder arthroplasty, marked poste- and patients with moderate to severe glenoid erosion rior or otherwise nonconcentric wear of the glenoid, se- did much better after total shoulder arthroplasty than vere joint contracture, and bone loss on the humeral humeral head replacement. Based on these data, the use side. Other arthroscopic procedures such as microfrac- of a glenoid component is recommended in shoulders ture arthroplasty and glenoidplasty (burring nonconcen- with preoperative glenoid erosion. tric wear) have been suggested, but their usefulness has not yet been substantiated in the peer-reviewed litera- Glenohumeral arthritis can occur after surgery for ture. shoulder instability, and in general occurs more often af- ter nonanatomic repairs where there is excessive short- Soft-Tissue Resurfacing With or Without Hemi- ening of the anterior capsule and subscapularis resulting arthroplasty Soft-tissue interposition arthroplasty has in severe limitation of external rotation. The reported received significant attention in recent years, given the results for arthroplasty for arthritis of this etiology are complications associated with early glenoid wear and not as good as those for primary arthritis. One reason the frequency of radiolucencies associated with glenoid may be that the patients are in general younger, and implantation. The two most common materials used are have higher physical demands and expectations. Two re- fascia lata, both allograft and autograft, and allograft cent studies showed definite improvements in range of knee meniscus. One early report of fascia lata interposi- motion and pain relief. However, both studies had rela- tion is promising, with failure in only one patient in tively high revision rates and some unsatisfactory re- whom the graft was found to have lost fixation at the sults. The survivorship of the components at 10 years time of revision surgery. However, the numbers are was 61% and is significant because the average age of small and follow-up has been short term. patients undergoing arthroplasty was 46 to 47 years in both studies. More recently, several centers have successfully used the lateral knee meniscus as an interposition tissue. The Glenoid component loosening has been recognized rationale for the use of the lateral meniscus is that it is as one of the most common reasons for revision shoul- tissue designed to withstand significant load with weight der arthroplasty surgery. Although radiolucency around bearing under normal physiologic conditions. The lateral the glenoid component occurs in a much higher number meniscus is used because it is more discoid in shape and of patients than the number that ultimately require revi- gives better glenoid coverage. It is secured to the gle- sion for glenoid loosening, the glenoid component re- noid surface in place of a prosthetic component using mains the most likely to fail of the shoulder arthroplasty bone anchors in the glenoid in a circumferential fashion. components. It has been shown in a series of 48 shoul- Early results show maintenance of the joint space radio- ders undergoing glenoid component revision surgery graphically and excellent functional results. Long-term that satisfactory pain relief was achieved in a much survival analysis of this construct is still not available. higher percentage of patients that had a new glenoid The effect of severe posterior glenoid wear is also not component inserted than in those who had glenoid com- clearly delineated at this point, but it may be a relative ponent removal without reimplantation. Patients who did not have reinsertion of a component underwent American Academy of Orthopaedic Surgeons 303

Shoulder Reconstruction Orthopaedic Knowledge Update 8 contraindication to the use of soft-tissue interposition disturbing the ligaments and deltoid. Care must still be because of the risk of continued bone loss that may taken not to violate the ligaments with the arthroscopic make future reconstructive options difficult or impossi- instruments. The surgeon must adequately assess for ble. complete bone removal. The most commonly missed bone is located superiorly and posteriorly, and symp- The primary indication for soft-tissue interposition toms may continue if resection is not thorough. arthroplasty is young patients with severe arthritis who are candidates for arthroplasty, but have a high likeli- Annotated Bibliography hood of needing revision surgery in the future because of their young age. In general, this includes patients in Rotator Cuff Tear their 40s and active, higher-demand patients in their early 50s. There is always a small risk of disease trans- Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup mission with use of allograft material, and recipients DM, Rowland CM: Surgical repair of chronic rotator should be made aware of this risk. Although the long- cuff tears. J Bone Joint Surg Am 2001;83:71-77. term results of this procedure are still not available and the indications are still developing, soft-tissue interposi- This is a prospective long-term study examining the results tion in the shoulder holds significant promise for the of open surgical repair and acromioplasty of chronic rotator treatment of arthritis in the young patient. cuff tears. Satisfactory pain relief was obtained in 96 of 105 shoulders. Tear size was the most important determinant of Acromioclavicular Joint Arthritis outcome with regard to active motion, strength, rating of re- sults, patient satisfaction, and need for revision. Symptomatic acromioclavicular joint arthritis is a clini- cal rather than a radiographic diagnosis. Examination Fenlin JM Jr, Chase JM, Rushton SA, Frieman BG: Tu- findings include tenderness with palpation at the acro- beroplasty, creation of an acromiohumeral articulation: mioclavicular joint and pain with cross-body adduction. A treatment option for massive, irreparable rotator cuff Radiographic changes are extremely common and do repairs. J Shoulder Elbow Surg 2002;11:136-142. not correlate with symptomatic pathology that requires treatment. Nonsurgical treatment of isolated acro- The authors discuss results of tuberoplasty in 20 patients. mioclavicular joint pain includes nonsteroidal anti- Overall results (improved pain relief and return to daily activ- inflammatory drugs, rest from inciting activity, and corti- ities) were good. costeroid injections. If the condition is associated with rotator cuff pathology, physical therapy may be of bene- Galatz LM, Griggs S, Cameron BD, Iannotti JP: Pro- fit. Nonsurgical treatment of at least 3 to 6 months is spective longitudinal analysis of postoperative shoulder generally recommended before surgical treatment function: A ten-year follow-up study of full-thickness ro- should be considered. tator cuff tears. J Bone Joint Surg Am 2001;83:1052- 1056. A persistently painful acromioclavicular joint that is not responsive to nonsurgical treatment is surgically The authors reported that early results of rotator cuff re- treated with a distal clavicle resection that can be per- pairs do not deteriorate with time in this prospective longitu- formed through an open or an arthroscopic approach. If dinal study. the procedure is performed through an open incision, care should be taken to repair the acromioclavicular lig- Halder AM, O’Driscoll SW, Heers G, et al: Biomechani- aments. The superior and posterior acromioclavicular cal comparison of effects of supraspinatus tendon de- ligaments are the most important for maintaining stabil- tachments, tendon defects, and muscle retractions. ity. Disadvantages of the open approach are that the lig- J Bone Joint Surg Am 2002;84:780-785. aments must be violated and subperiosteally removed from the distal clavicle. A portion of the deltoid is also The effects of supraspinatus tendon detachments, tendon removed from the anterior acromion and clavicle. This defects, and muscle retraction on in vitro force transmission by removal is of little consequence if appropriately re- the rotator cuff to the humerus were compared. paired, but failure to do so results in significantly com- promised outcome. Murray TF, Lajtai G, Mileski RM, Snyder SJ: Arthro- scopic repair of medium to large full-thickness rotator An arthroscopic distal clavicle resection is per- cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder formed with the arthroscope in the posterior or postero- Elbow Surg 2002;11:19-24. lateral portal into the subacromial space. The working instruments are inserted through the rotator interval Forty-eight arthroscopic repairs of medium to large rota- portal redirected into the subacromial space or through tor cuff tears were evaluated 2 to 6 years after surgery. There a separate portal to access the acromioclavicular joint. were 35 excellent, 11 good, 2 fair, and no poor results. Only This approach allows excision of the clavicle without one patient had clinical evidence of failed repair. 304 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 26 Shoulder Reconstruction Parsons IM, Apreleva M, Fu FH, Woo SL: The effect of Edwards TB, Boulahia A, Kempf J-F, Boileau P, Nemoz rotator cuff tears on reaction forces at the glenohumeral C, Walch G: The influence of rotator cuff disease on the joint. J Orthop Res 2002;20:439-446. results of shoulder arthroplasty for primary osteoarthri- tis: Results of a multicenter study. J Bone Joint Surg Am Results from this study of nine cadaveric upper extremi- 2002;84:2240-2248. ties indicate that the integrity of the rotator cuff has a signifi- cant effect on joint reaction forces. Rotator cuff tears are uncommon in primary gleno- humeral arthritis. This study examined the effect of full- Pearsall AW IV, Bonsell S, Heitman RJ, Helms CA, Os- thickness tears, partial-thickness tears, and fatty degeneration bahr D, Speer K: Radiographic findings associated with of the rotator cuff on the outcome. Supraspinatus tears were symptomatic rotator cuff tears. J Shoulder Elbow Surg not found to influence the postoperative outcome. Addition- 2003;12:122-127. ally, treatment of these tears did not influence outcome pa- rameters. However, shoulders with severe and moderate fatty Radiographs of 40 patients with a documented rotator cuff degeneration of the infraspinatus had poorer results. tear were compared with those of asymptomatic age-matched control patients. Results indicate that radiographs of patients Godeneche A, Boileau P, Favard L, et al: Prosthetic re- with rotator cuff tear have greater tuberosity radiographic ab- placement in the treatment of osteoarthritis of the normalities that are not seen in the asymptomatic patients. shoulder: Early results of 268 cases. J Shoulder Elbow Surg 2002;11:11-18. Postacchini F, Gumina S: Results of surgery after failed attempt at repair of irreparable rotator cuff tear. Clin This is a study reporting the results of 268 shoulder arthro- Orthop 2002;397:332-341. plasties for primary osteoarthritis. Good to excellent results were observed in 77% of patients and there was a 94% satis- This is a study of a small number of patients who had an faction rate. Mean active forward elevation was 145° postoper- open attempt at rotator cuff repair including deltoid detach- atively. In this study, glenoid radiolucent lines were present in ment and acromioplasty. At the time of surgery, the tears were 58% of cases and were associated with a less satisfactory re- found to be irreparable. Shoulder function deteriorated in 11 sult. Patients who underwent biceps tenodesis had better pain patients. The authors recommended against attempted open relief. Complications occurred in 8.6% of cases. repair of irreparable cuff tears because the functional results are generally poor. Hill JM, Norris TR: Long-term results of total shoulder arthroplasty following bone grafting of the glenoid. Warner JJ, Higgins L, Parsons IM IV, Dowdy P: Diagno- J Bone Joint Surg Am 2001;83:877-883. sis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg 2001;10:37-46. Bone grafting of the glenoid can restore bone stock in pa- tients with structural defects. According to results of this study, repair within 6 months of subscapularis tear may produce a better functional out- Iannotti JP, Norris TR: Influence of preoperative factors come. on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258. Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD: Natural history of asymptomatic ro- The purpose of this study was to evaluate the influence of tator cuff tears: A longitudinal analysis of asymptomatic full-thickness rotator cuff tears, preoperative erosion of gle- tears detected sonographically. J Shoulder Elbow Surg noid bone, radiographic evidence of subluxation of the hu- 2001;10:199-203. meral head, and preoperative range of motion on the outcome shoulder arthroplasty. Repairable full-thickness tears of the The natural history of asymptomatic rotator cuff tears was supraspinatus tendon did not affect outcome. Shoulders with studied over a 5-year period to determine risk of tear progres- severe or moderate glenoid erosion had better results with to- sion and development of symptoms. tal shoulder arthroplasty than hemiarthroplasty. Based on these results, it is recommended that a glenoid component be Glenohumeral Joint Arthritis inserted in shoulders with glenoid erosion. A repairable tear of the supraspinatus tendon is not a contraindication to the Antuna SA, Sperling JW, Cofield RH, Rowland CM: use of a glenoid component. Glenoid revision surgery after total shoulder arthro- plasty. J Shoulder Elbow Surg 2001;10:217-224. Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C, Cofield RH: Shoulder arthroplasty for arthritis after in- Glenoid component revision surgery was performed on stability surgery. J Bone Joint Surg Am 2002;84:1775- 48 shoulders. The indications for surgery were glenoid compo- 1781. nent loosening in 29 shoulders, implant failure in 14, and com- ponent malposition or wear leading to instability in 5 shoul- Arthroplasty was associated with significant pain relief. ders. Satisfactory pain relief was acute in 86% of patients who There was not a significant difference between the hemiar- had another glenoid component inserted and in 66% of pa- throplasty and total shoulder arthroplasty groups with regard tients who underwent glenoid component removal. Patients to external rotation, abduction, or pain. The survival of the who have bone grafting may be candidates for glenoid compo- nent placement after graft consolidation. American Academy of Orthopaedic Surgeons 305

Shoulder Reconstruction Orthopaedic Knowledge Update 8 components at 10 years was 61%. The data from these studies Gerber C, Fuchs B, Hodler J: The results of repair of suggest that arthroplasty in this particular group of patients is massive tears of the rotator cuff. J Bone Joint Surg Am associated with good pain relief; however, there were high 2000;82:505-515. rates of revision surgery and unsatisfactory results because of component failure instability and glenoid arthritis in the hemi- Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin arthroplasty group. MC: Fatty muscle degeneration in cuff ruptures: Pre- and postoperative evaluation by CT scan. Clin Orthop Trail IA, Nuttall D: The results of shoulder arthroplasty 1994;304:78-83. in patients with rheumatoid arthritis. J Bone Joint Surg Br 2002;84:1121-1125. Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone A clinical and radiologic analysis of 105 shoulder arthro- Joint Surg Am 1990;72:1193-1197. plasties in patients with rheumatoid arthritis was performed. Constant scores and American Shoulder and Elbow Surgeons Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Will- scores were improved, and both scores were statistically signif- iams GR: Postoperative assessment of shoulder func- icant. tion: A prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5:449-457. Classic Bibliography Neer CS II: Replacement arthroplasty for glenohumeral Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Op- osteoarthritis. J Bone Joint Surg Am 1974;56:1-13. erative repair of massive rotator cuff tears: Long term results. J Shoulder Elbow Surg 1992;1:120-130. Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am Brenner BC, Ferlic DC, Clayton ML, Dennis DA: Survi- 1982;64:319-337. vorship of unconstrained total shoulder arthroplasty. J Bone Joint Surg Am 1989;71:1289-1296. Rodosky M, Bigliani L: Indications for glenoid resurfac- ing in shoulder arthroplasty. J Shoulder Elbow Surg Burkhead WZ Jr, Hutton KS: Biologic resurfacing of 1996;5:231-248. the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg 1995;4:263-270. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD: Long-term functional outcome of repair of large and Gartsman G, Khan M, Hammerman S: Arthroscopic re- massive chronic tears of the rotator cuff. J Bone Joint pair of full-thickness tears of the rotator cuff. J Bone Surg Am 1991;81:991-997. Joint Surg Am 1998;80:832-840. Gartsman GM, Roddey TS, Hammerman SM: Shoulder Walch G, Boileau P: Prosthetic adaptability: A new con- arthroplasty with or without resurfacing of the glenoid cept for shoulder arthroplasty. J Shoulder Elbow Surg in patients who have osteoarthritis. J Bone Joint Surg 1999;8:443-451. 2000;82:26-34. 306 American Academy of Orthopaedic Surgeons

Chapter 27 Elbow and Forearm: Adult Trauma David Ring, MD Jesse B. Jupiter, MD Distal Humeral Fractures osteotomy provides the best exposure of the distal hu- merus. The authors of this study also report that with at- Fractures Involving the Metaphyseal Columns of the tention to detail in the creation and repair of the olecra- non osteotomy the rate of complications and revisions Distal Humerus specifically to address prominent wires is acceptable. Fractures of the distal humerus are usually bicolumnar, The use of two plates in orthogonal planes has be- and most will involve the articular surface. Although of- come well established in the treatment of fractures of ten depicted as Y- or T-shaped fractures with a simple the distal humerus. However, there is biomechanical articular split, it is becoming evident that these rela- support for the use of parallel plates placed on the di- tively simple fracture patterns are not as common as the rect medial and lateral aspects of the columns, and this more complex metaphyseal and articular fractures. Most configuration is often better suited to the treatment of fractures involve one of the following factors that in- complex fracture patterns. Newer plate designs include crease the challenge of surgical treatment: (1) low (dis- precontoured shapes and smaller 2.7-mm screws placed tal) fracture of one or both columns (at the level of the distally to facilitate internal fixation. base of the olecranon fossa); (2) metaphyseal fragmen- tation of one or both columns; (3) complex fragmenta- Total elbow arthroplasty is now an accepted treat- tion of the articular surface, including entirely or nearly ment option for older, less active patients with fractures entirely articular fragments (especially those with a of the distal humerus. Several studies, including a recent coronal plane fracture line). comparative study of arthroplasty and plate and screw fixation, document very good early results; however, The surgical treatment of fractures of the distal hu- long-term follow-up is needed because elbow arthro- merus remains unsatisfactory in approximately 25% of plasties have a limited life span and eventually wear patients in most reported series. Some series have re- out. In addition, patients who undergo total elbow ar- ported a greater complication rate in older patients, throplasty require a 5-kg lifting restriction, and patients probably because of poor bone quality, but perhaps also who undergo this procedure are more prone to infection resulting from more difficult injury patterns. On the and other complications than those who undergo total other hand, two recent series evaluated the results of hip or knee arthroplasty. The best candidate for total el- treatment using the Disabilities of the Arm, Shoulder, bow arthroplasty is an older, infirm, and inactive patient and Hand outcomes instrument and found reasonably with a fracture of the distal humerus, or a patient with a good restoration of function from the patient’s perspec- fracture of the distal humerus with an elbow joint that is tive. already compromised by rheumatoid arthritis. Olecranon osteotomy for exposure of fractures of Fractures Involving Primarily the Articular Surface the distal humerus has waned in popularity primarily because of problems related to the wires or screws used The discussion of fractures involving primarily the artic- to repair the osteotomy. Alternative exposures com- ular surface of the distal humerus is often limited to monly in use include the recently introduced triceps- fractures of the capitellum. It is now known that iso- reflecting anconeus pedicle modification of the triceps lated fractures of the capitellum are uncommon. An ap- elevating exposure of Bryan and Morrey; the traditional parent fracture of the capitellum nearly always extends Campbell exposure (midline triceps split), with addi- into the lateral trochlear lip (the so-called coronal shear tional elevation of the triceps off of the proximal ulna; fracture) and may also involve a fracture of the lateral and the reintroduced Allonso-Llamas exposure (in epicondyle, impaction of the posterior aspect of the lat- which the triceps is elevated off of the back of the hu- eral column, fracture of the posterior aspect of the tro- merus, but its insertion onto the olecranon is preserved). However, a recent cadaver study showed that olecranon American Academy of Orthopaedic Surgeons 307

Elbow and Forearm: Adult Trauma Orthopaedic Knowledge Update 8 Figure 1 Illustration of the lateral lip of the trochlea (1), lateral epicondyle (2), poste- rior aspect of the lateral column (3), posterior trochlea (4), and medial epicondyle (5). Apparent fractures of the capitellum usually involve region 1, and injuries with greater complexity can involve fractures in regions 2 through 5. (© Copyright D. Ring, MD & J.B. Jupiter, MD.) Figure 2 Three-dimensional reconstruction of a CT image; this is useful for under- standing complex articular fractures of the distal humerus and planning surgical treat- ment. (© Copyright D. Ring, MD & J.B. Jupiter, MD.) Figure 3 When the articular fragments do not fit, as shown in this photograph, there CT reconstructions with the ulna and the radius sub- is impaction of the posterior aspect of the distal humerus, which must be elevated to tracted from the image are invaluable for understanding allow accurate reduction of the articular fragments. (© Copyright D. Ring, MD & J.B. the injury and planning surgical treatment (Figure 2). Jupiter, MD.) Traction radiographs and fluoroscopy can help define the fracture pattern, but they are not as useful for pre- chlea, and fracture of the medial epicondyle (Figure 1). operative planning as three-dimensional CT reconstruc- Other variations such as fractures involving primarily tions because they are usually obtained at the time of the trochlear side of the joint are occasionally encoun- surgery after the administration of anesthesia. tered. Surgical fixation can usually be achieved through a When a semicircular fracture fragment is identified lateral muscle interval with elevation of the extensor anterior to the distal humerus on the lateral radiograph carpi radialis brevis and part of the extensor carpi radia- of a patient with an injured elbow, surgeons should look lis longus off of the supracondylar ridge and anterior for a second arc or semicircle on the fragment, which in- humerus. If the lateral collateral ligament and epi- dicates that the fracture involves the trochlea. A tro- condyle are intact, it is often possible to work through chlear defect is often apparent on the AP view. Because an interval anterior to the lateral collateral ligament these features and the more complex fractures of the (through the common extensor muscles) and rely on re- distal humeral articular surface can be difficult to detect duction of the metaphyseal fracture lines. For patients on standard radiographs, CT is especially helpful in di- with more complex fractures, there is nearly always a agnosing these injuries. In particular, three-dimensional fracture of the lateral epicondyle, which can be mobi- lized along with the origins of the lateral collateral liga- ment and common extensor muscles. The elbow joint can then be subluxated, allowing a good view of the an- terior articular surface of the distal humerus. If the pos- terior aspect of the trochlea or the medial epicondyle is fractured, exposure through an olecranon osteotomy may be preferable. If the fracture fragments do not seem to fit back onto the intact portions of the distal humerus, additional impaction of the intact distal humerus should be sus- pected (Figure 3). In this situation, it will be necessary to hinge open the posterior aspect of the lateral column and the posterior aspect of the trochlea to properly re- 308 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 27 Elbow and Forearm: Adult Trauma align the anterior fracture fragments. The articular frag- fractures (type 2), and complete head fractures (type 3). ments are secured with countersunk screws (screws with There are few data in the literature to support any sub- threads on the head, such as Herbert screws, can be classification based on the size or displacement of par- used), small threaded Kirschner wires, or screws enter- tial head fractures. Several important factors are not ac- ing from the nonarticular parts of the distal humerus, counted for in this classification system, and they are such as the posterior aspect of the lateral column. The only partially accounted for in the more recent compre- lateral epicondyle is secured with a tension band wire to hensive classification of fractures, including: (1) the incorporate the common extensor fascia; a screw or a number of fracture fragments; (2) lost or unrecoverable plate is also used if the fragment is large enough. articular fragments; (3) central impaction and deforma- tion of the radial head; (4) the quality of the fracture Ideally, active-assisted exercises and use of the arm fragments (amount of subchondral bone, osteoporosis); for light daily activities are started the day after surgical and (5) metaphyseal comminution. These factors all will fixation of a fracture of the distal humerus. However, if have a substantial impact on attempts at surgical repair the fracture is complex or the bone quality is poor and of a radial head fracture. In particular, a recent study the fixation is therefore not optimal, it may be prefera- suggested that patients with fractures of the entire ra- ble to immobilize the elbow for 4 weeks before initiat- dial head that create more than three articular frag- ing exercises. A healed stiff elbow will be easier to sal- ments have high rates of early failure, nonunion, and vage than a nonhealed elbow, particularly in patients poor forearm rotation after surgical fixation. with complex fractures. Excision of a complex fracture of the radial head Radial Head Fractures without prosthetic replacement is still a viable treatment option. To do this safely, surgeons must make sure that Isolated radial head fractures usually involve part of the there is no forearm ligament injury by using the recently radial head and heal well with nonsurgical treatment. described radius pull test and ensure that there is no Sometimes they are displaced enough to block forearm fracture of the coronoid (terrible triad). Although it is rotation and benefit from surgical treatment. The most usually preferable to treat an elbow fracture-dislocation important complication of isolated partial radial head with either repair or replacement of the radial head, fractures is elbow stiffness, and the most important as- reasonable results have been reported after radial head pect of treatment is mobilization of the elbow. resection as long as the coronoid is not also fractured. Excision of the radial head without prosthetic replace- As documented in two recent case series, nonsurgi- ment is considered primarily in older patients with lim- cally treated minimally displaced fractures of the radial ited demands and simple injury patterns. neck will occasionally fail to heal. The prevalence of nonunion is obscured for several reasons: (1) nonunion Partial excision of the radial head has traditionally of the radial head is usually asymptomatic; (2) radio- been associated with less optimal results. Even a small graphs are rarely obtained until union in the treatment portion of the radial head can be important to stability of patients with this type of fracture; and (3) a fracture of the forearm or elbow. In the setting of an unstable of the radial head that is unhealed 1 year after the in- fracture-dislocation of the forearm or elbow, if a partial jury may still eventually heal 2 years or longer after the radial head fracture has inadequate fragments for re- injury. pair, it may be preferable to proceed with prosthetic re- placement. Fractures of the radial head—particularly complex fractures involving the entire head and neck—are often Surgical repair should be used only for patients with associated with one of the following five injury types: simple fractures with three or fewer fragments with (1) an Essex-Lopresti fracture-dislocation of the fore- good quality bone and little or no impaction. The im- arm or a variant thereof; (2) rupture of the medial col- plants must be placed directly laterally, with the arm in lateral ligament complex; (3) dislocation of the elbow; neutral rotation to avoid impingement on the ulna with (4) dislocation of the elbow with fractures of the radial forearm rotation. Another rough guide for placement is head and coronoid process—the so-called terrible triad provided by the arc defined by the radial styloid and of the elbow; and (5) an olecranon fracture-disloca- Lister’s tubercle. Implants placed on the articular sur- tion—usually with an apex posterior fracture of the face of the radial head must be countersunk beneath the proximal ulna or olecranon (the so-called posterior articular surface. Monteggia lesion). In each type, the associated fractures and ligament injuries may compromise forearm or el- Several metal radial head prostheses are in common bow instability, thereby increasing the importance of the use. Two studies support the use of a loose-stemmed radial head. metal prosthesis that acts as a stiff spacer, and another study supports the use of a bipolar prosthesis that is ce- Although the classification system of Mason is still mented into the neck of the radius. Surgeons should be used, it is often modified. The Mason classification dis- careful not to place a prosthesis that is too long or wide tinguished nondisplaced fractures (type 1), partial head and always err toward using a slightly smaller prosthesis American Academy of Orthopaedic Surgeons 309

Elbow and Forearm: Adult Trauma Orthopaedic Knowledge Update 8 Figure 5 Three-dimensional reconstruction of a CT image showing that even very small coronoid fractures can be associated with recurrent elbow instability, particularly when they involve the anteromedial facet of the coronoid. (© Copyright D. Ring, MD & J.B. Jupiter, MD.) Figure 4 Radiograph showing wear of the capitellum that can result when a metal The lateral collateral ligament characteristically fails radial head prosthesis is too long; the medial side of the ulnohumeral joint will be by avulsion of its lateral epicondylar origin, with mid- hinged open in such instances. Therefore, it is important not to place too large an substance tears and avulsion from the ulna occurring implant. (© Copyright D. Ring, MD & J.B. Jupiter, MD.) less commonly. This facilitates repair with either suture anchors or drill holes through the bone of the lateral because the major problem is overstuffing of the joint, epicondyle. Instability after dislocation of the elbow is which can lead to problems with wear of the capitellar usually associated with fracture of the radial head and cartilage and potential instability or malalignment of the coronoid process. Elbow dislocations without major elbow (Figure 4). Some of the older prosthetic designs associated fractures are also occasionally unstable. had stems that were too big for the average radial neck, Whether they occur in older or younger patients after a which could result in inadequate placement with the ra- high-energy injury, there are usually extensive avulsions dial head not well seated into the shaft. Biomechanical of the common extensor and flexor muscles from the studies have confirmed the ability of metal radial head distal humerus. Older patients may have primarily prostheses to restore near-normal stability to the elbow lateral-sided injuries, with a tendency for the elbow to after radial head excision. rotate on the relatively preserved medial soft tissues. Some patients with unstable elbow dislocations have a Elbow Dislocations small fracture of the anteromedial facet of the coronoid process—a variant of posteromedial varus rotational in- It is now well recognized that elbow dislocations are as- stability pattern injuries (Figure 5). Unstable elbow dis- sociated with complete or near-complete disruption of the locations are treated with either extensive soft-tissue re- capsuloligamentous stabilizers of the elbow and that the attachment to the distal humerus, cross pinning of the progression of injury is typically from lateral to medial. It elbow joint, or hinged external fixation. is possible to dislocate the elbow with the anterior band of the medial collateral ligament still intact. The focus of Coronoid Fractures treatment has shifted from the medial to the lateral col- lateral ligament complex. The medial collateral ligament Although a recently published biomechanical cadaver is repaired only if treatment of associated fractures and study suggested a limited effect of small coronoid frac- the lateral collateral ligament fails to restore stability. tures on elbow instability, clinical data document that even very small fractures can lead to troublesome elbow instability. For instance, although the coronoid fractures associated with terrible triad pattern fracture- dislocations of the elbow are nearly always transverse fractures that are less than 30% of the coronoid height, terrible triad elbows can dislocate in spite of cast immo- 310 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 27 Elbow and Forearm: Adult Trauma bilization, are prone to dislocation after surgical treat- simple olecranon fractures, and good results have been ment (particularly if radiocapitellar contact is not re- reported; however, 20% of patients had a second sur- stored), and can have a high prevalence of unsatisfactory gery for plate removal. Furthermore, it may not be wise treatment results. Because of the poor results associated to rely on screws to secure a small osteopenic proximal with the treatment of this type of fracture, many surgeons fragment. The long-term results of successful surgical re- are routinely repairing the coronoid fracture, usually pair of olecranon fractures are good. with suture placed through drill holes in the ulna. Diaphyseal Forearm Fractures Fractures of the anteromedial facet of the coronoid process are usually associated with injury to the lateral Mechanics collateral ligament complex and can be difficult to man- age. These have been labeled posteromedial varus rota- Several recent studies have examined the impact of rota- tional instability pattern injuries. This type of fracture is tional malalignment of the radius and ulna on forearm ro- repaired with a plate and screws through a medial expo- tation. These studies consistently show that rotational sure between the two heads of the flexor carpi ulnaris malalignment of the ulna has less impact on forearm ro- (where the ulnar nerve usually sits), more anteriorly tation than radius malrotation. In both the radius and the through a split in the flexor pronator mass, or both. ulna, forearm motion was not impacted unless there was substantial malalignment (at least 30° malrotation)—an Large coronoid fractures are nearly always associ- amount of malalignment that is unlikely to occur in the ated with an olecranon fracture-dislocation. These frac- management of patients. Prior studies have shown a more tures typically involve multiple fragments, particularly substantial impact with even minor angular malalign- when part of a posterior olecranon fracture-dislocation. ments of the radius and ulna, particularly loss of the nor- They can be accessed and manipulated through the ole- mal radial bow. cranon fracture itself and fixed with a dorsal plate and screws with or without an additional medial plate. The A biomechanical study of dynamic compression plates results of treatment of anterior transolecranon fracture- applied to transverse diaphyseal osteotomies of the radius dislocations have been quite good, whereas the treat- showed that even relatively small plates could achieve a ment of posterior olecranon fracture-dislocations has bending stiffness comparable to that of the intact bone been associated with a greater number of complications and that longer plates with bicortical screws at the ends of and revisions and diminished results. Patients with large the plates had better torsional stiffness. This is consistent fractures with complex comminution or poor bone with the findings of previous studies and emphasizes the quality may occasionally benefit from protection with advantages of longer plates and bicortical screws in a set- hinged external fixation. ting with substantial torsional stresses such as the forearm. These advantages may be even more pronounced in pa- Olecranon Fractures tients with comminuted fractures. The Mayo classification of olecranon fractures charac- Ulnar Fractures terizes fractures based on the three most important fac- tors in treatment considerations: comminution, displace- Two recently published meta-analyses of the treatment ment, and fracture-dislocation. of isolated fractures of the ulnar diaphysis (the so-called nightstick fracture) identified only retrospective case se- There is wide variation regarding the treatment of ries and therefore could not make definitive recommen- olecranon fractures. A biomechanical study found that a dations regarding treatment. Fractures with greater than large screw was best for internal fixation of olecranon 50% of displacement or 10° of angulation can impact fractures, but reported that the stability was insufficient forearm rotation. Because surgical treatment of these to allow active elbow exercises. Conversely, internal fix- fractures is straightforward, it is recommended that sur- ation of olecranon osteotomies and fractures with small geons have a low threshold for surgical treatment for caliber wires with immediate active mobilization has displaced fractures. For less displaced fractures, nonsur- been shown to be very successful in practice, at least gical treatment—even simple symptomatic treatment— when specific techniques are used. will usually result in union with good function, but the time to complete healing can be quite prolonged. There- The major disadvantage of tension band wiring con- fore, surgical treatment is also a reasonable option for tinues to be a high rate of subsequent surgical proce- motivated patients with less displaced fractures. dures for removal of symptomatic prominent hardware, which has been reported in one long-term study as rang- Diaphyseal ulnar fractures with anterior or lateral ing between 43% and 81% (depending on technique); dislocation of the proximal radioulnar joint (anterior or however, in another study, it was reported to be only lateral Monteggia lesions) are uncommon in adults. 13% when specific techniques intended to limit the Plate and screw fixation of the ulna in anatomic align- prominence of the wires were used. Plates are becoming ment usually restores good function. Open reduction of a more popular treatment option for fixation of even the proximal radioulnar and radiocapitellar joints is American Academy of Orthopaedic Surgeons 311

Elbow and Forearm: Adult Trauma Orthopaedic Knowledge Update 8 rarely necessary. Residual malalignment of these joints usually reflects residual malalignment of the ulna. Posterior Monteggia fractures occur more commonly in adult patients, particularly when posterior olecranon fracture-dislocations are included. Few of these injuries occur at the diaphyseal level. Most occur at the level of the metaphysis (just distal to the coronoid process) or through the olecranon (olecranon fracture-dislocation). These injuries are often associated with fractures of the radial head and coronoid and injury to the lateral collat- eral ligament complex. Posterior Monteggia fractures are more challenging to treat, and the results are not as pre- dictable because (1) it can be difficult to obtain solid fix- ation of the proximal ulna fragment, particularly in pa- tients with osteoporosis; (2) the fracture of the coronoid can be comminuted and difficult to repair; (3) the fracture of the radial head increases the risk of diminished fore- arm rotation and proximal radioulnar synostosis; and (4) the ulnohumeral joint can be unstable, and this is often not well appreciated. Complications and secondary proce- dures can be limited by using a plate contoured to wrap around the dorsal surface of the olecranon and proximal ulna to provide more secure fixation of the proximal frag- ment; by obtaining good exposure and secure fixation of the coronoid; by obtaining stable fixation or replacement of the radial head; and by repairing the lateral collateral ligament when injured. Radial Fractures Figure 6 Preoperative radiograph of a patient with a radial diaphysis fracture. Many such fractures do not have associated injury to the distal radioulnar joint and can be Although textbooks describe isolated fractures of the managed with early mobilization after plate fixation. Preoperative radiographic align- ulnar diaphysis without proximal or distal radioulnar ment and location of the radius fracture can be helpful, but surgeons should always joint injury (nightstick fractures), isolated radial frac- base treatment decisions on a careful evaluation of the distal radioulnar joint after tures are often omitted, with classification systems skip- plate fixation. (© Copyright D. Ring, MD & J.B. Jupiter, MD.) ping directly to Galeazzi fractures (fracture of radial di- aphysis and dislocation of the distal radioulnar joint). A Annotated Bibliography recent article suggests that isolated fractures of the dia- physeal radius are unlikely to be associated with major Distal Humeral Fractures injury to the distal radioulnar joint (triangular fibrocar- tilage complex) when the ulnar fracture is greater than Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey 7.5 cm from the radiocarpal joint. It may be unwise to MB, Sanders RW: A comparison of open reduction and be complacent about the distal radioulnar joint based internal fixation and primary total elbow arthroplasty in on the location of the fracture, but what this study sup- the treatment of intraarticular distal humerus fractures ports is the idea that many isolated fractures of the ra- in women older than age 65. J Orthop Trauma 2003;17: dius occur without major radioulnar ligament injury 473-480. (Figure 6). After stable anatomic fixation of the radius, the distal radioulnar joint should be evaluated and com- The authors of this study retrospectively reviewed 24 pa- pared with a preoperative examination of the opposite, tients older than 65 years with bicondylar (C2 or C3) fractures uninjured side. In the absence of substantial instability, of the distal humerus that were treated with either total elbow immediate active mobilization may be safe and worth- arthroplasty (12 patients) or plate and screw fixation (12 pa- while. If the distal radioulnar joint is unstable there are tients). At a short-term follow-up of between 2 and 6 years several treatment options: (1) repair of a large ulnar sty- (average just under 4 years), the functional results were some- loid fracture if present; (2) repair of the triangular fibro- what better in the total elbow arthroplasty than the internal cartilage complex; (3) immobilization of the forearm in fixation group, with an average arc of flexion of 113° versus midsupination; and (4) cross-pinning of the radius and 100° and an average Mayo Elbow Performance Index of 95 the ulna in midsupination. versus 88 points, respectively. 312 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 27 Elbow and Forearm: Adult Trauma Pajarinen J, Bjorkenheim JM: Operative treatment of tures is desirable: A prospective randomised study of type C intercondylar fractures of the distal humerus: two protocols. Injury 2002;33:801-806. Results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg 2002;11:48-52. In this study, 60 patients with minimally displaced frac- tures of the radial head were prospectively randomized to un- In this study, 8 of 18 patients (all of whom were older than dergo either immediate active mobilization or 5 days of splint 50 years) had an unsatisfactory result after plate and screw fix- immobilization. All patients achieved excellent results. Pa- ation of a bicolumnar fracture of the distal humerus. Poor tients treated with immediate mobilization had less pain and bone quality and open fracture were also associated with infe- better elbow function at 1 week. There were no adverse conse- rior results. quences of immediate mobilization. Ring D, Jupiter JB, Gulotta L: Articular fractures of the Moro JK, Werier J, MacDermid JC, Patterson SD, King distal part of the humerus. J Bone Joint Surg Am 2003; GJ: Arthroplasty with a metal radial head for unrecon- 85:232-238. structible fractures of the radial head. J Bone Joint Surg Am 2001;83:1201-1211. In this study, 21 patients with apparent fractures of the capitellum had more complex fractures of the articular surface In this study, 25 patients with metal radial head prostheses of the distal humerus. The authors report that fixation with were evaluated an average of 39 months after injury. The aver- buried screws and wires achieved healing with slight settling of age flexion arc was 132°, the average forearm arc was 146°, the the fracture fragments in two patients and no major osteone- average disabilities of the arm, shoulder, and hand score was crosis. Ten patients required a second surgical procedure, and 17, and the average Mayo Elbow Performance Index score five patients had an unsatisfactory functional result related to was 80. There were eight unsatisfactory results related to asso- persistent elbow stiffness. ciated injuries, psychiatric problems, and secondary gain. Asymptomatic lucencies around the stem were the rule be- Ring D, Gulotta L, Chin K, Jupiter JB: Olecranon os- cause the implant functions as a spacer and is not intended to teotomy for exposure of fractures and nonunions of the have a tight fit in the radial neck. distal humerus. J Orthop Trauma 2004;18:446-449. Pomianowski S, Morrey BF, Neale PG, Park MJ, In this study, 45 patients had an apex distal chevron- O’Driscoll SW, An KN: Contribution of monoblock and shaped olecranon osteotomy repaired with Kirschner wires di- bipolar radial head prostheses to valgus stability of the rected out the anterior ulnar cortex distal to the coronoid pro- elbow. J Bone Joint Surg Am 2001;83-A:1829-1834. cess, and bent 180° and impacted into the olecranon proximally with two 22-gauge figure-of-8 stainless steel ten- In this study, three metal radial head prostheses were sion wires. The only failure occurred in a patient who returned shown to restore valgus stability in the medial collateral liga- to athletic activities too soon. Only six patients (13%) had a ment deficient elbow close to the status with an intact radial subsequent surgical procedure performed specifically to re- head. move the wires. Ring D, Psychoyios VN, Chin KR, Jupiter JB: Nonunion Schildhauer TA, Nork SE, Mills WJ, Henley MB: Exten- of nonoperatively treated fractures of the radial head. sor mechanism-sparing paratricipital posterior approach Clin Orthop 2002;398:235-238. to the distal humerus. J Orthop Trauma 2003;17:374-378. The authors of this study describe five patients with a ra- Extra-articular fractures (Opthopaedic Trauma Associa- dial neck nonunion after a minimally displaced radial head tion [OTA] type A) and simple articular distal humeral frac- fracture. These fractures are usually asymptomatic. tures with simple or multifragmentary metaphyseal involve- ment (OTA type C1 and C2) were treated by elevating the Ring D, Quintero J, Jupiter JB: Open reduction and in- triceps off of the back of the humerus and working through ternal fixation of fractures of the radial head. J Bone the medial and lateral paratricipital windows (an exposure de- Joint Surg Am 2002;84:1811-1815. scribed previously by Allonso-Llamas). In this study, 56 patients in whom an intra-articular frac- Wilkinson JM, Stanley D: Posterior surgical approaches ture of the radial head had been treated with open reduction to the elbow: A comparative anatomic study. J Shoulder and internal fixation were evaluated at an average of 48 Elbow Surg 2001;10:380-382. months after injury. The authors report that good results were obtained in all of the patients with isolated partial radial head In this study, the median-exposed articular surface for tri- fractures, in 4 of 15 of those with partial radial head fractures ceps splitting, triceps reflecting, and olecranon osteotomy ap- that were part of a complex injury to the elbow or forearm, proaches was 35%, 46%, and 57%, respectively. and in 11 of 12 of those with fracture of the entire head into two or three large fragments. Among patients with fracture of Radial Head Fractures the entire head into greater than three fragments, 13 of 14 had an unsatisfactory result, with three early failures and six non- Liow RY, Cregan A, Nanda R, Montgomery RJ: Early unions. mobilisation for minimally displaced radial head frac- American Academy of Orthopaedic Surgeons 313

Elbow and Forearm: Adult Trauma Orthopaedic Knowledge Update 8 Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch the arm (a mainstay of effective treatment and not associated DS: Radius pull test: Predictor of longitudinal forearm with major problems in prior clinical series). instability. J Bone Joint Surg Am 2002;84:1970-1976. Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Jo- In this sequential cutting study in cadavers, the authors sefsson PO: Comparison of tension-band and figure-of- showed that after radial head resection 3 mm of proximal ra- eight wiring techniques for treatment of olecranon frac- dial migration with longitudinal traction indicated disruption tures. J Shoulder Elbow Surg 2002;11:377-382. of the interosseous membrane and migration of 6 mm or greater indicated gross longitudinal instability with disruption In a long-term study of olecranon fractures, one subset of of all ligamentous structures of the forearm. patients was treated with tension band wiring and the other was treated with a simple figure-of-8 wire. The authors report Elbow Dislocations that the results were comparable for both groups, with a high rate of hardware removal occurring in both groups after ten- McKee MD, Schemitsch EH, Sala MJ, O’Driscoll SW: sion band wiring (81% of patients) and after figure-of-8 wiring The pathoanatomy of lateral ligamentous disruption in (43%). complex elbow instability. J Shoulder Elbow Surg 2003; 12:391-396. Karlsson MK, Hasserius R, Karlsson C, Besjakov J, Jo- sefsson PO: Fractures of the olecranon: A 15- to 25-year Six patterns of injury to the lateral collateral ligament in- followup of 73 patients. Clin Orthop 2002;403:205-212. jury were observed in 62 patients with a surgically treated dis- location or fracture-dislocation of the elbow (proximal avul- In a long-term follow-up of 70 patients who were treated sions in 32, bony avulsions of the lateral epicondyle in 5, for olecranon fractures, the authors report excellent or good midsubstance ruptures in 18, ulnar detachments of the lateral results in 96%, slight loss of elbow flexion and extension and collateral ligament in 3, ulnar bony avulsions in 1, and com- mild or moderate degenerative changes in over 50%. The au- bined patterns in 3). The common extensor origin was also thors conclude that adequately treated fractures of the olecra- ruptured in 41 patients (66%). non have a favorable long-term outcome. Coronoid Fractures Diaphyseal Forearm Fractures Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of Dumont CE, Thalmann R, Macy JC: The effect of rota- the elbow with fractures of the radial head and coro- tional malunion of the radius and the ulna on supination noid. J Bone Joint Surg Am 2002;84-A:547-551. and pronation. J Bone Joint Surg Br 2002;84:1070-1074. The authors of this article describe 7 of 11 terrible triad el- In this cadaver study, the authors report that substantial bows that redislocated in a splint after manipulative reduction. rotational malalignment of the radius and/or ulna was neces- Five patients, including four who were treated with resection sary before forearm rotation was affected. of the radial head, experienced redislocation after surgical treatment. Only four patients reported satisfactory results, all Handoll HH, Pearce PK: Interventions for isolated of whom had retained the radial head and two of whom had diaphyseal fractures of the ulna in adults. Cochrane lateral collateral ligament repair. The subsequent letters to the Database Syst Rev 2004;2:CD000523. editor adds additional perspective to the current concepts re- garding the treatment of these injuries. A review of trials was performed to determine the effects of different treatment methods (in adults) for isolated frac- Olecranon Fractures tures of the ulnar shaft. The authors concluded that there was insufficient evidence from randomized trials to determine the Bailey CS, MacDermid J, Patterson SD, King GJ: Out- most appropriate treatment method. come of plate fixation of olecranon fractures. J Orthop Trauma 2001;15:542-548. Hertel R, Eijer H, Meisser A, Hauke C, Perren SM: Bio- mechanical and biological considerations relating to the Near normal motion, strength, and disabilities of the arm, clinical use of the Point Contact-Fixator: Evaluation of shoulder, and hand scores were observed after plate fixation the device handling test in the treatment of diaphyseal of 25 displaced olecranon fractures. The authors report that fractures of the radius and/or ulna. Injury 2001;32(suppl 20% of patients requested plate removal. 2):B10-B14. Hutchinson DT, Horwitz DS, Ha G, Thomas CW, Ba- In this study of 83 diaphyseal forearm fractures in 52 pa- chus KN: Cyclic loading of olecranon fracture fixation tients that were repaired using a Point Contact-Fixator (Syn- constructs. J Bone Joint Surg Am 2003;85:831-837. thes, Paoli, PA), 76 bones healed with callus without further intervention. Stripping of the hexagonal slot was reported to As might be expected based on the size of the implants be a problem at removal of the implant. alone, a large screw limits displacement of an olecranon os- teotomy better than Kirschner wires with a tension band wire Kasten P, Krefft M, Hesselbach J, Weinberg AM: How in biomechanical tests in cadavers. Unfortunately, the authors does torsional deformity of the radial shaft influence the of this study interpreted their data as disproving the tension band concept (a basic engineering principle that cannot be dis- proved) and as discouraging immediate active mobilization of 314 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 27 Elbow and Forearm: Adult Trauma rotation of the forearm? A biomechanical study. J Or- Chapman MW, Gordon JE, Zissimos AG: Compression thop Trauma 2003;17:57-60. plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169. The authors of this study report that significant loss of forearm rotation was not observed until a minimum of 30° of Josefsson PO, Gentz CF, Johnell O, Wendeberg: Disloca- rotational malunion. tions of the elbow and intraarticular fractures. Clin Or- thop 1989;246:126-130. Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am Mason ML: Some observations on fractures of the head 2001;26:228-235. of the radius with a review of one hundred cases. Br J Surg 1959;42:123-132. In this review of 40 patients with Galeazzi fracture- dislocations, the authors suggest that more proximal fractures McKee MD, Wilson TL, Winston L, Schemitsch EH, Ri- are less likely to have distal radioulnar joint instability. Among chards RR: Functional outcome following surgical treat- 22 fractures in the distal third of the radius (within 7.5 cm of ment of intra-articular distal humeral fractures through the radiocarpal joint), 12 had intraoperative distal radioulnar a posterior approach. J Bone Joint Surg Am 2000;82: joint instability. Among 18 more proximal fractures, only one 1701-1707. had intraoperative distal radioulnar joint instability after plat- ing of the radius. Regan W, Morrey BF: Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 1989;71:1348-1354. Classic Bibliography Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS: Anderson LD, Sisk D, Tooms RE, Park WI III: Transolecranon fracture-dislocation of the elbow. J Or- Compression-plate fixation in acute diaphyseal fractures thop Trauma 1997;11:545-550. of the radius and ulna. J Bone Joint Surg Am 1975;57: 287-297. Ring D, Jupiter JB, Simpson NS: Monteggia fractures in adults. J Bone Joint Surg Am 1998;80:1733-1744. Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN: Prosthetic radial head components and proximal Schemitsch EH, Richards RR: The effect of malunion radial morphology: A mismatch. J Shoulder Elbow Surg on functional outcome after plate fixation of fractures 1999;8:471-475. of both bones of the forearm in adults. J Bone Joint Surg Am 1992;74:1068-1078. Broberg MA, Morrey BF: Results of treatment of fracture-dislocations of the elbow. Clin Orthop 1987;216: 109-119. American Academy of Orthopaedic Surgeons 315