Upper Limb





Very few

- young labourer with severe disabling elbow pain

- trial in POP at 90o for 6 weeks


Poor function

- adjacent joints cannot compensate for loss of function





- high failure rate especially flail elbow with poor bone stock






- very good results

- 97% 10 year survival Coonrad-Morrey prosthesis


Other Dx 

- OA / post-traumatic arthritis / nonunion

- tend to have worse survival than RA



- elbow joint commonly involved

- 90% of haemophiliacs


Acute unreconstructable fracture > 60






Poor soft tissue cover skin triceps


Under 60 years


Charcot Joint


Implant Types


1. Fully Constrained 

- have highest failure


2. Semi- constrained 


Coonrad-Morrey TER

- sloppy hinge

- allow some varus-valgus


3. Unconstrained 



- stems on ulna & humerus to prevent loosening

- poly / metal bearing

- require MCL & LCL for stability


Technique Latitude Total Elbow Replacement


Total Elbow Latitude RATotal Elbow Latitude RA



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

- unconstrained / semiconstrained

- anterior humeral flange with bone graft important for longetivity


Lateral position

- arm over bolster


Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve with vessiloops


Total Elbow Ulna Nerve


Triceps Options


A. Split in midline

- feathered off bone medially and laterally

- left attached distally


B.  Bryan-Morrey

- triceps elevated from subperiosteally

- from ulna to radial side

- periosteum left attached on radial side


C.  Triceps sparing

- elevate triceps tendon medially and laterally

- identify and protect ulna and radial nerve medially and laterally

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


Distal Humerus

- elevate and tag LCL / MCL for later repair

- elevate anterior capsule off humerus


Dislocate Elbow


Prepare humerus


1.  Size capitellum and trochlea with spool

- judge off distal humerus

- insert into olecranon and over radial head


2.  Stabilise centre of rotation

- most important

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

- pass pin through


3.  Resect olecranon fossa, find entry to IM canal

- pass IM guide


4.  Attach resection jig to rotation and IM pins

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

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

7.  Trial


Prepare ulna and radius


1.  Broach IM canal of ulna

2.  Pass IM jig, centre on ulna

- EM points towards ulna styloid

- fixed in position with 3 pins

3.  Use jig to 

- resect radial head

- burr prepares ulna lateral to medial

4.  Trial


Humeral / ulna and radius prosthesis inserted

- simplex cement

- cement restrictors



- collateral ligaments reattached through humeral prosthesis

- closure triceps over drain with Ethibond


Post op

- POP 1 - 2 weeks till wound healed




Morrey et al JBJS Am 1998

- TER in rheumatoid arthritis

- followed for 10 years

- 92% survival rate

- 10% incidence of serious complication requiring re-operation

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


Morrey et al JBJS Am 2010

- TER in post traumatic arthritis

- 69 patients followed for 9 years

- 19% failure rate

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

- most patients with failure < 60 years






Total Elbow Replacement InfectionTotal Elbow Joint Infected 2Infected TER



- 4-5%

- most common cause of failure


Risk factors for infection

- previous surgery

- previous infection

- stage IV RA

- drainage post-op

- re-operation for any reason

- poor skin



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

- POP for 2 weeks post op to achieve wound healing




Often follows superficial infection or bursitis

- need aggressive treatment of any superficial infection

- can often salvage joint with early debridement and washout


If signs of bony infection / loosening 

- 2 stage revision

- resection arthroplasty


Total Elbow Replacement Cement SpacerTotal Elbow Replacement Cement Spacer 2


Intraoperative fracture




More common in unconstrained

- 6%


Transient neuropraxia

- 5%


Triceps failure

- 2%




Revision TER


Total elbow loose humeral component








1. Removal Loose body


Elbow scope Loose Body


2. Excison of osteophytes

- coronoid

- olecranon

- aiming to improve ROM / prevent impingement


Elbow Stiffness Posterior ImpingementElbow Stiffness Posterior Debridement


3. Elbow Stiffness Capsular Release

- capsular contraction can limit range

- anterior capsulotomy

- risk to median nerve anteriorly


4. Management OCD lesions


Elbow scope Radial Head OCDElbow OCD


5.  Synovectomy

- RA, haemophilia

- usually results in marked blood loss

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


6.  Washout sepsis


7. Excision of Radial Head

- useful combined with synovectomy in RA

- can excise head and 2-3mm of neck

- to ensure stability should keep annular ligament




Abnormal elbow scarring

Extensive HO

Previous ulna nerve transposition






4mm scope 

2.7mm wrist scope




A.  Patient lateral

- hip supports

- arm over L shaped bolster


Elbow Lateral Decubitus


B.  Patient supine

- anterior portals and arthroscopy with arm on arm board

- posterior portals and arthroscopy with arm bent over patient




Outline surface markings with a pen

- epicondyles, radial head, olecranon

- medial and lateral supracondylar ridge

- draw ulna nerve


PIN landmarks

- anterior to radial head

- posterior to mobile wad


Anterior elbow arthroscopy


Lateral portals


A.  Proximal Anterolateral portal



- intial viewing portal



- 1-2 cm proximal to lateral epicondyle

- just anterior to lateral intermuscular septum

- onto anterior humerus

- walk down into joint

- insufflate with 20 mls

- incision in skin

- same technique to insert portal



- radial nerve

- moved further away by insufflation

- most dangerous portal

- do first before swelling obscures anatomy


Elbow Arthroscopy Anterior Compartment


B.  Anterolateral Portal



- working portal

- microfracture capitellar OCD



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

- in sulcus between radial head and capitellum

- PIN most in danger here

- avoid distal / anterior placement


Elbow Arthroscopy AnterolateralElbow Scope Anterolateral Portal


Medial Portals


Proximal Anteromedial Portal 



- 2cm proximal to the medial epicondyle

- just anterior to humerus / medial intermuscular septum

- ulna nerve behing medial epicondyle

- median nerve and brachial artery anterior



- insert needle under vision

- incision in skin

- pass haemostat under vision


Elbow Scope Anterolateral Portal



- removal of loose body

- visualise chondral surfaces ulnohumeral and radiocapitellar


Anteromedial portal



- 2cm anterior and 2cm distal to medial epicondyle


Posterior elbow arthroscopy




Posterior loose bodies

Olecranon tip / fossa impingement

Retrograde capitellum OCD drilling



- ulnar nerve when debriding medially




Posterocentral portal

- 3 cm proximal to tip olecranon

- in midline


Posterolateral portals



- 2 - 3 cm proximal to tip olecranon

- in line lateral edge of triceps


Soft spot portal


Anconeus triangle

- olecranon tip / radial head / lateral epicondyle

- through skin, anconeus, capsule



- posterior cutaneous nerve



- retrograde drilling of capitellum


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




Nerve injuries


All nerves at risk especially PIN



- no LA

- minimise tourniquet time

- minimise pump pressure to 40


If PIN palsy post op

- need to explore

- usually cut

- very difficult to defend medicolegally

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


Vascular injury











Capitellar OCD



Adolescents & young adults


Usually between 12 - 21 years 


Throwing athletes / gymnasts


Little Leaguer's Elbow

- combination of capitellar OCD and MCL injury

- a repetitive throwing injury / seen in pitchers




1.  Trauma & Overuse


Common throwing sports / gymnastics

- dominant limb predominates

- repetitive overuse

- valgus overload on radiocapitellar joint 

- fatigue failure of the subchondral area 

- overlying cartilage fails under shear stress & separates


Capitellum loaded more heavily

- less able to take load than radial head articular surface

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


2.  Ischaemia


Predominant blood supply to capitellum from posterior vessels

- histopathology shows osteonecrosis


Pappas Classification   


Category 1  - patients < 13 years of age 

Category 2  - 13 years to adulthood 

Category 3  - adults 


Found better prognosis with younger patients 

- especially with open capitellar growth plate

- respond better to non operative treatment




Dominant arm / history of over-use


Pain activity related


Limited range

- very common presentation


Clicking, grinding, catching, locking

- ? Loose bodies




Tender over lateral aspect elbow


Loss of extension


Radio-capitellar compression test

- active supination and pronation with arm fully extended


Examine MCL


Iwase's Classification Xray


Grade 1

- localised flattening and translucency


Capitellar OCDElbow OCD


Grade 2


A:  Small fragment without sclerosis

B:  Small fragment with sclerosis


Elbow OCD Type 2BElbow OCD Type 2B CT


Grade 3

- in situ loose body




Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellum involved

- not sure if is earlier spectrum of same disease




Fluid interface denotes detachment / instability


Capitellar OCD MRI




Non Operative




Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD




Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months




Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

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

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

- 25/30 early stage lesions healed

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

- suggest early surgical intervention in advanced OCD

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






1.  Failure non operative treatment

2.  Loose bodies

3.  Instability / displacement


Large / salvageable fragments


A.  Stable / Drill in situ


Elbow OCD InsituElbow OCD Retrograde Drilling


Arthroscopic technique

- anterograge via anterolateral portal if possible

- retrograde via ACL jig / posterolateral portal with elbow flexed


B.  Unstable / Fixation


Arthroscopic technique

- via soft spot portal


Takahara et al JBJS Am 2007

- demonstrated fragment fixation or reconstruction better than removal

- fragment fixation with bone graft


Small / unsalvageable Fragments


A. Arthroscopic Debridement


Elbow Scope Capitellar OCDElbow Scope OCD Debridement


Schoch et al Arthroscopy 2010

- arthroscopic debridement in 13 patients

- follow up average 3 years

- symptomatic relief

- 6/13 had to cease some sport


B.  Microfracture


Elbow Scope OCDElbow scope OCD Microfracture


C.  Abrasion


Elbow OCDElbow OCD Abrasion


Large Chondral Defects


A.  Mosaicplasty


Ovesen et al J Should Elbow Surg 2011

- 10 patients treated with mosaicplasty

- average age 21

- incorporation in all patients

- significant improvement in Mayo elbow scores




Coronoid Process Fracture

BackgroundClassification Coronoid Fractures


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



1.  Provides anterior buttress

2.  Anterior capsule and brachialis attach to coronoid

2.  Anterior band of the MCL attaches to it

- distally and medially on sublime tubercle


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


Fracture patterns



Anteromedial facet fragment




Most commonly associated with elbow dislocations

Anteromedial facet fractures may be caused by varus / rotational force


Regan and Morrey Classification


Coronoid Process Classification


Type I 

- usually stable

- shear fracture not avulsion fracture

- may rarely cause residual instability in elbow dislocation


Coronoid Fracture Type 1Coronoid Fracture Type 1 CT


Type II 

- 50% coronoid

- elbow usually unstable

- lose attachment of capsule

- ORIF screws or sutures

- any ? about stability use hinged fixator


Coronoid Fracture Type 2


Type III

- > 50% coronoid

- Uncommon

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

- ORIF with screw / sutures / anteromedial buttress plate

- again may need hinged fixator


Type 3 Coronoid FractureCoronoid Fracture Type 3


Operative Management


Surgical approach


1.  Universal posterior approach

- if performing surgery for complex dislocation

- allows medial and lateral access to joint


2.  Lateral approach through radial head

- if excising radial head, then replacing


3.  Medial approach

- isolate and protect ulna nerve  

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

- important if fracture is anteromedial


4.  Approach through fractured olecranon




Type 1

- capsular suture repair


Type 2 / 3

A.  Screws (AP or PA)

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


Anteromedial fragment

- medial approach / buttress plate


Coronoid Process Buttress Plate


Unrepairable / unstable

- reconstruct with radial head, iliac crest, or allograft


Cubitus Varus



Occurs 10% of supracondylar humeral fractures

- varus malunion


Lateral condyle fracture

- AVN trochlea


Elbow Cubitus Varus


Growth arrest of medial aspect physis

- rare

- post traumatic




Usually little functional defect


Cosmetic problem

- appearance can be unacceptable to parents and child




Does not correct with time


Operative Management


1.  Lateral closing wedge osteotomy of the supracondylar region 

- perform at skeletal maturity

- metaphyseal not diaphyseal

- preserve medial cortex

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

- 1mm of wedge for each degree

- fixation with plate


2.  Complex Osteotomies

- posterior approach

- bilateral plates

- for severe deformities


Elbow post distal Osteotomy


3.  Young patient / open physis

- guided growth

- application lateral 8 plate





Anatomy Pathology

EpidemiologyElbow Dislocation LateralComplex Elbow Dislocation AP


6 /100 000

- second most common dislocation after shoulder








1.  Obtain and maintain a concentric reduction 

2.  Achieve a painless and functional ROM


Associated Injuries


20% neuropraxia (ulna nerve / AIN)




Final position of Ulna Relative to Humerus







1.  Complete 


2.  Subluxed / Perched (Drop sign)

- < 10 % patients


Simple / Complex


25-50% associated with fracture




Acute / Chronic / Recurrent


Bony Anatomy


Ulnohumeral Joint


Trochlea and ulna highly conformed

- trochlea covered by cartilage in arc 300o

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

- trochlea 6o valgus which creates carrying angle


Radiocapitellar Joint


60% of load at elbow

- concave radial head with capitellum

- posteromedial 2/3 articulates with sigmoid notch ulna

- anterolateral 1/3 has no cartilage /  safe zone


Anterior part of radial head fractures normally

- part of spectrum in dislocation

- radial head important secondary stabiliser, especially when MCL deficient


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


Distal Humerus


Tilted anteriorly 30o in lateral plane

- 5o internally in transverse plane

- 6o of valgus in front plane


Elbow Valgus Carrying angleElbow Trochela Anterior Angulation


Centre of rotation

- trochlea

- centre of rotation offset anteriorly from humeral shaft


Elbow Centre of Rotation




LCL anatomy elbow



- Varus Stability


LCL has 4 Components


1. Annular Ligament

- anterior edge supinator crest to posterior edge


2. Radial Collateral Ligament

- CEO to annular ligament

- fan-shaped


3. Lateral Ulna Collateral Ligament 


Most important restraint to PL instability

- CEO to supinator crest


Must protect in Kocher approach

- in line with edge of anconeus, deep to it

- must protect in surgical approach between anconeus and ECU


4.  Accessory Collateral Ligament

- from crest to diffusely over annular ligament




Elbow MCL



- primary restraint to valgus stability

- especially in flexion

- this is the position in the throwing athlete

- in extension radial-capitellar joint important


3 parts


1. Anterior band

- CFO to sublime tubercle

- most important


2. Transverse band

- olecranon - sublime

- groove for ulna nerve


3. Posterior band

- CFO to olecranon


Constraints to Elbow Instability 


Primary Static


1.  Ulnohumeral articulation

- olecranon and coronoid


2.  MCL 


3.  LCL


Secondary Static


1.  Radio-capitellar joint


2.  CFO / EFO


3.  Capsule


Dynamic Stabilisers


Anconeus - PLR stability


Triceps / Brachialis / Biceps


Pathoanatomy / Horii circle


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

- anterior band of MCL is the last torn


Stage 1


Damage to LCL

- Posterolateral Rotatory Subluxation

- this can reduce spontaneously


Stage 2


Damage to anterior and posterior capsule

- posterior capsule quite insignificant

- anterior important


Coronoid appears perched on trochlea

- incomplete PL dislocation

- concave medial edge of ulna on trochlea

- can be easily reduced or even by patient


Stage 3


Medial disruption


Stage 3A


Anterior band of MCL intact

- postero-lateral dislocation

- pivots about this anterior band

- often seen with radial head and coronoid fracture


Reduce with traction, varus and pronation


Maintain stability with hand pronated

- stability provided by anterior MCL


Stage 3B


Entire MCL disrupted

- varus / valgus / rotatory instability present after reduction


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


Stage 3C


Unstable at 90o


Entire distal humerus stripped / CFO / CEO

- reduction maintained only with flexion > 90o


Hinged External Fixator

External fixator elbow 1External Fixator Elbow 2




1.  Persistent instability despite ORIF and LCL repair


2.  Gross acute instability, not suitable for surgery


3.  Delayed treatment > 4 weeks


Compass hinge  / S&N


Compass Hinge Lateral XrayCompass Hinge AP Xray


Compass HInge Medial ClinicalCompass Hinge Clinical


Set up

- two incomplete rings proximal and distal

- hinge in centre

- can be used actively or passively

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

- rings posterior, open anteriorly

- rings compatible with ilizarov equipment

- hinge can also be adjusted in the varus valgus plane

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


Compass Hinge Centre of Rotation


Key is distal humeral axis

- imagine axis is in spool at end of humerus

- open laterally to identify capitellum

- open medially to identify trochlea

- confirm centre of rotation on lateral


A. Insert medial and lateral 3.5 mm pins partially

- place external fixator over pins but this can be difficult

- adjust pins so hinge slides easily over them

- insert pins 2mm


B.  Insert a single pin through axis of rotation

- slightly easier to apply the external hinge over the pin

- may not have to open the medial side as much

- only slight to identify and protect the ulna nerve


Medial Humeral half pin

- posterior to ulna nerve

- ensure proximal ring is perpendicular to humerus

- use two hole rancho cube with centering sleeve

- drop off undersurface off ring

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

- need bicortical fixation


Lateral humeral pin

- anterior to radial nerve

- 2 hole post with single hole rancho

- allows angulation of pin from proximal to distal

- also angle posterior to anterior


Ulna pins

- 4mm pins into subcutaneous border

- must reduce elbow first and hold reduced whilst inserting pins

- ring must be perpendicular to ulna

- usually put elbow in 90 degrees of flexion

- proximal pin off proximal side of ring wth rancho cube

- bicortical usually into coronoid

- check is stable reduction

- insert second +/- third pin distally


Acute Elbow Dislocation Management

Elbow Dislocation Lateral


1.  Reduction under IV / conscious sedation

- assistant applies traction in slight flexion

- second person corrects lateral displacement by manipulating olecranon medially

- flexion to 90o


2.  Post reduction assess stability

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

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

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


3.  Confirm concentric reduction

- 2 view check x-rays mandatory


4.  Stable elbow

- manage in POP 90o 2 weeks

- weekly check xray

- then begin ROM exercises


Elbow ROM Brace


Management Problems


A. Simple Elbow Dislocation


B.  Complex Elbow Dislocation

- radial head fracture

- coronoid process fracture

- Terrible Triad (MCL / coronoid / radial head)

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

- capitellar fractures



- difficult problem

- need to prepared at all times to

- ORIF / replace radial head

- repair / reconstruct LCL

- ORIF / suture coronoid

- repair MCL

- apply external fixator


1.  Simple Elbow Dislocation


A.  Stable Simple Elbow Dislocation


 Simple Elbow DislocationElbow Simple Dislocation Reduced






Assess Stability 

- OT if unstable > 45o in pronation


X-ray weekly


Mobilise 2 - 3 weeks


If FFD at 6/52 > 40o

- night extension splint

- turnbuckle elbow extension splints


Josefsson et al 1987 JBJS AM

- randomised 30 patients with elbow dislocations

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

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

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

- loss of extension was commonest complication

- seen 50% more in operative group


B.  Unstable simple elbow dislocation


Uncommon but not rare

- may be intact medially

- avulsed LCL and CEO




1.  Kocher approach & Reconstruct / Repair LCL + CEO

- lateral ulna collateral ligament is usually avulsed from lateral condyle

- centre of rotation is centre of capitellum

- place suture anchor

- repair anconeus and ECU over top

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

- ROM brace


2.  Elbow still unstable / address MCL

- usually avulsed from medial epicondyle 

- usually can do direct repair / suture anchors

- mid-substance probably have to reconstruct with Palmaris


Medial approach centred on medial epicondyle

- locate, mobilise and protect ulna nerve

- proximally between brachialis and triceps

- distally between pronator teres and brachialis

- can reflect PT

- protect median nerve distally


C.  Chronic Simple Elbow dislocation


Missed injury / delayed presentation

- open reduction

- removal scar tissue

- repair / reconstruction LCL

- +/- hinged external fixation


2.  Dislocation with Radial Head Fracture


Manage as per radial head classification


Hotchkiss Modified Mason class (R&G)


Type I


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

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

- diagnose by LA injection and full pronation and supination


Non operative treatment


Type II


Displaced fracture of the head or neck 

- > 2mm and amenable to fixation


Motion may be mechanically limited with or without significant joint incongruity 


CT Radial Head FractureRadial Head ORIF



- Kocher approach


- LCL repair / reconstruction


Type III


Severely comminuted fracture of the radial head and neck 

- not reconstructable 

- Titanium replacement


Radial Head Replacement


Ashwood et al JBJS Am 2004

- 16 patients titanium monoblock radial head

- 81% G/E at 2 years


Radial Neck Fracture


Morrey et al J Orthop Trauma

- concern regarding loss of rotation with plating

- prefer to ORIF with oblique screws or radial head replacement


3.  Dislocation with Coronoid Fracture


Elbow Dislocation Large Coronoid Fragment


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



- provides anterior buttress

- attachment of capsule and brachialis

- anterior band of the MCL attaches to it


Manage as per Regan and Morrey Classification

- ORIF / repair type I / II


Regan and Morrey Classification


Type I 

- stable as nothing attaches to tip 

- shear fracture, not avulsion fracture


Type II 

- 50% coronoid

- elbow usually unstable / ORIF or suture


Type III

- > 50%

- uncommon

- can be comminuted

- ORIF or suture


Elbow Dislocation Large Coronoid Fragment 2




Universal posterior approach

- single posterior skin incision

- elevate flaps laterally and medially as required

- lateral approach to repair ulna LCL

- medial approach to repair coronoid


Medial approach

- isolate and protect ulna nerve  

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

- important if fracture is medial




1.  Screw / buttress plate


Coronoid Buttress Plate APCoronoid Buttress Plate Lateral


2.  Sutures through capsule / Lasso repair 

- tie over drill holes through olecranon / endobutton


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


Note:  Acknowledged by world class names as being difficult


4.  Dislocation + Terrible Triad


Complex Elbow Dislocation APComplex Elbow Dislocation Lateral



- radial head fracture + coronoid fracture + MCL


Surgical Algorigthm


Universal Posterior Approach


1.  Type 2 radial head

- Kocher approach


- repair / reconstruct ulna LCL

- reassess stability

- if unstable, additional medial approach

- isolate and protect ulna nerve

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

- repair / reconstruct MCL

- assess stability

- rarely may require external fixator


2.  Type 3 radial head

- Kocher approach

- excise radial head

- attempt ORIF / suture coronoid process through this gap

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

- replace radial head

- repair / reconstruct LCL

- reassess stability

- may then need medial approach and MCL repair / reconstruction

- reassess stability

- may need hinged external fixator


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


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


A.  Anterior / Trans Olecranon Fracture Dislocations


Less common, better outcomes because

- coronoid fragment usually larger / easier to ORIF

- collaterals often intact

- radial head often intact



- universal posterior approach

- ORIF / suture coronoid through olecranon fracture

- TBW or plate for olecranon fracture

- can repair coronoid with lag screw from olecranon plate

- Kocher approach

- ORIF / replace radial head

- repair / reconstruct LCL

- reassess stability

- +/- repair reconstruct MCL


B.  Posterior Monteggia Fracture


Elbow Dislocation Posterior Monteggia


More common, worse outcome because

- LCL more likely to be ruptured as well

- coronoid more likely to be comminuted

- radial head fracture



- ORIF coronoid through olecranon fracture

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

- +/- ORIF /replace radial head

- +/- repair / reconstruct LCL

- +/- hinged fixator


6. Other


Dislocation with distal radius fracture


Dislocated Elbow Fracture wristDislocated Elbow Fractured Wrist



Distal Biceps Tendon Rupture



Dominant arm of middle aged men

- between 40 and 60




Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load




Degenerative changes seen on histology





- retracted / rupture of lacertus fibrosis

- minimally retracted



- small - partial tears of some fibres

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




Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength




Distal Biceps Rupture


Acute onset pain / distal swelling / bruising


Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact


Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon


O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test


Biceps Tendon Hook Test



- supination > flexion


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




May see bony avulsion from radial tuberosity




Confirm diagnosis


A.  Complete tear / retracted

- relatively easy to diagnose


Distal Biceps Rupture MRI


B.  Partial tear


Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue oedema


MRI Biceps Partial TearBiceps Partial tear


Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears






Indication for complete tears


Elderly patients who do not require full strength and endurance


Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

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






Young active patients with recent rupture 

- may be more difficult with chronic tears




Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury


One incision

- single anterior incision

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

- theoretical higher risk PIN injury

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


Operative Technique:  One incision technique with endobutton


Set up

- supine, arm board, tourniquet



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

- S shaped


Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound


Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final


Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

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

- allows space for dorsal cortex of radius


Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which


Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity


Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN


Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II


Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair


Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52




Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength


Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side


John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients


Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques


Mazzocca et al Am J Sports Med 2007

- biomechanical study

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


Lo et al Arthroscopy 2011

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

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

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


2 incision Boyd and Anderson Technique




Anterior Henry approach as before


Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius


Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator



- performed through bone tunnels




Greewal et al JBJS Am 2012

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

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance


Partial Tears


Management Options


Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%


Surgical Treatment of a Partial Tear


Biceps ApproachBiceps Partial TearBiceps Partial Tear 2Biceps Partial Tear 3


Repair with suture anchors


Biceps Suture Anchor Repair


Chronic Tears


> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion


Typically run into problems > 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction

- secure to radial tuberosity with endobutton first

- then weave through distal biceps stump

- pulve taft weave through tendon


Hamstring autograft biceps reconstruction


Biceps reconstruction with tendoachilles allograftDistal biceps reconstruction with allograft






Injury LCNFA

Injury PIN

Loss of extension

- more common with chronic injuries

Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture


2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture


In the second group fixation can be very difficult




Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns


Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation


Elbow AP NormalElbow Normal AP 4 degrees valgus


CT scan


Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension


Muller's Classification


Type A: Extra-articular fracture


Distal Humerus Fracture


Type B: Uni-condylar fracture

- lateral /  medial


Elbow Medial Condyle FractureElbow Lateral Condyle Fracture


Type C: Bi-condylar fracture


Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture


Operative Management




Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO




1.  ORIF


2.  Distal humeral replacement / osteoporotic and highly comminuted fractures


Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o


McKee et al JSES 2009

- RCT 42 patients > 65 years of age


- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA



- good treatment if unable to ORIF

- high level of skills required

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

- otherwise must replace ulna +/- linked prosthesis


3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function


Distal Humerus Non Operative




Extra-articular fracture


Distal Humerus Extraarticular ORIF


1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates


2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact


3.  Split triceps

- feather with osteotome off ulna medial and laterally


Intra-articular fracture


Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy


Technique for Intra-articular fracture


Distal Humerus ORIF APDistal Humerus ORIF Lateral



- lateral decubitus with bolsters

- arm over bolster

- tourniquet

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


Elbow Lateral Decubitus


Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected


Chevron Olecranon Osteotomy


Chevron Osteotomy



- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

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

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

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes


Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II


Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

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

- fix with locking screws

- ensure not in olecranon or coronoid fossa  


Assess ROM

- no block to motion

- good stability


Check II


Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  


ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW


Post op 


POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)




G/E 75%





- loss of 10 - 20o extension common


Humeral non union


Olecranon osteotomy non union

- 5%

- bone graft and plate


Ulna nerve palsy

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

- treat with neurolysis + transposition


Painful Hardware

- most common

- re-fracture risk if remove both plates


Adult Lateral Condyle Fracture


Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2




Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea


Management Options


These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate


Adult Medial Condyle Fracture


Elbow Medial Condyle Fracture




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

When medial epicondyle is fractured, flexor muscles pull fragment distally




1.  Medial approach

- find and protect ulna nerve

- ORIF with screws


2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

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


Transcondylar Fracture




Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone




Non-displaced fractures are treated with splinting or percutaneous pinning


Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement


Capitellar Fracture


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


Elbow Capitellar FractureCapitellar Fracture CT SagittalCapitellar Fracture CT Axial


Type I

- Hans Steinthal fracture

- fracture of the capitellum in the coronal plane

- involves large part of the osseous portion of capitulum

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




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


Open reduction


A. Posterolateral / Kocher approach

- between aconeus and ECU


B. Lateral approach

- between EDC and ECRB

- may place PIN at increased risk


One or two headless compression screws

- front to back

- buried


Capitellar Fracture ORIF0001Capitellar Fracture ORIF0002


Type II

- Kocher Lorenz fracture               

- affects primarily articular cartilage and very little underlying bone

- these usually cause few subsequent joint problems



- healing potential is minimal & excision is recommended


Lateral Epicondylitis / Tennis Elbow



Lateral : Medial 9:1




4th & 5th decades

- M = F

- 75% dominant arm 


50% of regular tennis players

- especially > 2 hrs / week




Insertion pathology / Enthesopathy


Over-extension of the elbow with supination / pronation




Lateral epicondyle

- anconeus from posterior face

- ECRB and EDC from anterior face (CEO)

- ECRL and BR from lateral supracondylar ridge


Differentiate ECRB from ECRL

- ECRB tendinous insertion onto lateral epicondyle

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



- apex of lateral epicondyle



- radial nerve between brachialis and BR

- divides at level of radial head

- enters supinator at this level (radial tunnel)




1.  OCD capitellum / radial head

2.  Radial tunnel / supinator / PIN syndrome

3.  PLRI

4.  OA, RA

5.  Referred Pain / C6-7 radiculopathy

6.  Enthesopathy

7.  Annular ligament tears


Risk factors



- poor technique

- poor grip

- hard court surfaces

- strings too taut



- plumbers

- painters




Starts as micro-tear in ECRB 

Get high grade partial tear




Angiofibrotic hyperplasia

- marked fibroblast proliferation

- extensive vascular hyperplasia

- disorganised collagen production

- may go on to dystrophic calcification


Disruption of parallel orientation of collagen fibres 

- invasion of fibroblasts and vascular granulation type tissue

- without an acute or chronic inflammatory component




History of overuse

Pain lateral elbow

Backhand in tennis main problem




Localised Swelling



- few degrees loss of extension = CEO

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


Tender ECRB

- 5 mm distal and anterior to CEO



- pain with resisted wrist dorsiflexion with elbow extended


Examine for Stability - PLRI

Examine Supination / Pronation - radiocapitellar OA

Examine C spine




Radial Tunnel Syndrome

- tenderness 3-4 cm distal to lateral epicondyle

- pain with resisted thumb / IF and supination




Usually normal

25% soft tissue calcification


Tennis Elbow CalcificationTennis Elbow Bone Spur








Will demonstrate tears and oedema on T2


Elbow MRI Lateral Epicondylitis


High grade partial tear


Tennis elbow High grade tear MRI




Non Operative




6-9 months

- successful ~ 75- 85%


Rest Phase


Complete rest lasting for 3-6/52

-  avoid precipitating factors



- oral or topical



- wrist in extension

- cock up wrist splint


Forearm tennis band

- limit muscle expansion

- may create new force direction


HCLA injection

- find patient's maximum tenderness deep to fascia 

- repeat 2-3 times over 6-12 months

- peri not intra-tendinous

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

- risks of local skin depigmentation and CEO rupture


Conditioning Phase


Once pain settled

- Extensor origin stretching 

- Wrist extension exercises (1lb increments)

- eccentric muscle training

- ART (active release technique)

- Activity modification / change racquet and stroke


Tyler et al J Should Elbow Surg 2010

- RCT using eccentric muscle training

- significant improvement in outcome


Adjuctive Therapy


1.  Shock wave lithotripsy


Meta-analysis of RCT

- minimal effect comparted with placebo


2.  Autologous Blood / PRP Injections


Peerbooms et al Am J Sports Med 2010

- RCT autologous blood v corticosteroid

- superior outomes with plasma cell injections at one year


3.  Botox Injections


Improvements compared with placebo

Inferior to corticosterioid


Operative Management




Failure of good non-operative management

- > 6 - 12/12



- open debridement

- percutaneous tenotomy

- arthroscopic

- radiofrequency microtenotomy


Open debridement


3 cm incision 

- centred on CEO

- ECRB is deep and posterior to ECRL

- ECRL muscular at this point


Surgical dissection

- Detach ECRB

- Debride degenerative tissue

- Decorticate underlying CEO

- +/- reattach ECRB


Tennis Elbow ReleaseTennis Elbow Release 2


Tennis Elbow Release 3Tennis Elbow 4



- Z lengthen

- denervate sensory nerves to epicondyle

- combine with decompression PIN

- cover with anconeus flap in chronic or recurrent cases



- splint 10 days

- gentle ROM to 6/52

- then strengthening exercises


Arthroscopic Release


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





- inadvertant release LCL



- posterior cutaneous nerve forearm

- runs 1.5 cm anterior to lateral epicondyle on BR fascia



- rare, but can be devastating




Dunn et al Am J Sports Med 2008

- retrospective study of 92 elbows over 12 years

- open release

- 84% good to excellent results


Baker et al Am J Sports Med 2008

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

- 87% patient satisfaction


Dunkow et al JBJS Br 2004

- RCT open v percutaneous tenotomy

- earlier return to work and faster recovery


Meknas et al Am J Sports Med 2008

- RCT of open release v microfrequency tenotomy

- no difference in pain relief

- better grip strength at 12 weeks

Medial Epicondylitis / Golfers Elbow



10% of elbow tendonitis




Overuse injury

- poor swing in golf

- poor throwing technique

- overuse of topspin in tennis

- occupational (repetitive hammering / screwing)


Some patients also have lateral epicondylitis




Tenderness CFO


Stimulate pain

- flexion of WJ with fingers resisting

- resisted pronation 

- resisted ulna deviation


May have ulna nerve symptoms




Rule out OA / OCD elbow




MCL insufficiency

- must differentiate from MCL instability

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




Non-Operative Management


As per tennis elbow


Operative Management


Surgical Release


Medial incision

- identify and protect ulna nerve

- release of CFO

- protection of MCL

- debridement of scar and bony prominence

- drill holes into epicondyle

- reattachment of CFO

- + / - Ulnar nerve decompression


Post op

- splint

- no resisted wrist flexion / pronation 6 - 8 weeks

- no sport for 4 - 6 months




Segal 1992

- small series 

- 11 of 16 good results with operative release


Vangness JBJS Br 1991

- 35 operative cases

- felt the underlying pathology was a tear in the CFO

- incomplete healing

- treatment as described above

- 34/35 good or excellent results

- 1 patient could not return to sport




Forearm Fractures

AnatomyPost op BBFF


Radial bow radius

- important for rotation


Interosseous membrane

- Z pattern

- proximal radius to distal ulna




Direct blow

- ulna / night stick


Ulna Fracture Night Stick





- Proximal 1/3 ulna fracture with radial head dislocation


Elbow Monteggia FractureElbow Monteggia Fracture ORIF


Monteggia Variant

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


Monteggia Variant APMonteggia Variant Lateral



- distal 1/3 radial fracture with DRUJ disruption


Galleazzi APGalleazzi LateralGalleazzi Xray APGalleazzi Xray Lateral


Both bone foream fractures


Bone bone forearm fracture APBBFF Lateral


Associated Injuries


Ulna can be compound

Compartment Syndrome


Compound Ulna




Joint above and below



- always assess radial capitellar line on two views


DRUJ disruption

- widened space between R & U

- radial shortening > 5 mm

- ulna styloid fracture




Isolated single bone


Both bone


Fracture of one bone with ligament rupture

- Galleazzi, Monteggia


Fractures of bone bones with ligament rupture


Non operative Management





- < 10o angulation


Ulna Fracture Undisplaced



- completely undisplaced

- maintenance radial bow


Operative Management




Intramedullary fixation

- children (good remodelling potential)

- prophylaxis to prevent pathological fracture


Ulna Intramedullary Wire


External Fixation

- severe injury / compound


Plate fixation


Ulna Plating




Anatomical reduction with absolute stability

- length

- rotation

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




Forearm Fractures Plate LateralForearm Fractures Plate AP





- approach between ECU / FCU





- between FCR and radial artery



- between BR and pronator teres

- supinate forearm

- elevate supinator from ulna to radial




Incident DRUJ instability

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

- < 5% if > 7.5 cm


Galleazzi ORIF 1Galleazzi ORIF 2


Plate distal radius

- assess DRUJ stability

- if stable, early ROM

- unstable, splint in supination

- if still unstable, ensure that radius is anatomical

- may have to repair TFCC / ORIF ulnar styloid

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


Galleazzi ORIF APGalleazzi ORIF Lateral


Yohe et al Hand 2017

- irreducible dorsal dislocations usually due to extensor tendonds, or fracture fragments

- no soft tissue block to volar dislocations


Tsismenakis et al Injury 2017

- 7/66 (11%) incidence of DRUJ instability after fixation

- 4/7 had ulnar styloid fracture

- may need ORIF ulnar styloid / fixation of TFCC to obtain stability

- can pin DRUJ proximal to fossa





- 2%

- exclude infection


Radial Fracture Non Union CTUlna Non Union






- > 10o angulation leads to loss of ROM



- osteotomy


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







- excise non union 

- debridement

- ABx cement spacer + external fixator

- eliminate infection


Obtain union

- BG and plate


Compartment syndrome

- don't close fascia

- good haemostasis




Risk factors

- fractures at same level / Monteggia

- proximal fractures

- open fractures

- head injuries

- bone grafting

- ORIF through single incision

- delayed surgery > 2 weeks





- usually posterior approach

- elevate ECU from ulna

- exposes synostosis and radius

- application of bone wax to bone after debridement

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

- worst results with proximal synostosis

MCL Insufficiency

AetiologyTommy John Surgery


Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity





- lose velocity / accuracy


Develop medial pain


40% ulna nerve symptoms




Pain on palpation of anterior bundle MCL


CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion


Jobes test


Valgus stress with elbow flexed 25o to unlock olecranon

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

- problem is shoulder ER



- lie patient prone

- apply valgus stress


Elbow MCL Test ProneElbow MCL Test Prone 2


Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain


MIlkers Sign 1Milkers Sign 2




Elbow MCL Anatomy




40% calcification MCL


Stress view

- > 3mm difference from opposite side




Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings




Non Operative






- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction


Really amounts to 6/12 rest

- problem for professional athletes




Tommy John Surgery


Named after famous American baseball pitcher

- first to have this surgery




1.  Repair

- not often able to be done

- perhaps in acute tear


2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described


UCL reconstruction


Tommy John Surgery


Numerus techniques described


Palmaris longus / gracilis graft


Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP


Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve


Figure of 8

- tension at 30o

- suture both limbs together to improve tension




Immobilise for 10/7

ROM brace for 4/52


No throwing for 6/12

No sport for 12/12




Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months


Posterior Elbow Impingement




Cause posteromedial pain

- probably related to subtle UCL instability


May be protective




Pain posteromedially with full extension




Identify posterior olecranon osteophytes




Arthroscopic Resection


Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective

Myositis Ossificans


Elbow Myositis OssificansElbow Myositis Ossificans




Parosteal OS

- bone is not continuous with cortex in MO




3% incidence in elbow joint trauma to some degree


Head + elbow joint trauma > 90%




Ectopic bone may ossify ligaments and capsule

- does not respect anatomical boundaries

- can completely envelope ulna nerve

- may form radio-ulnar synostosis


Usually in brachialis




Elbow HO




Show mature trabeculation

Define anatomical location


Elbow CT Posterior HOElbow CT HO Anterior







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

- recommends do not resect till about 18/12

- well defined trabeculae on x-ray


Excision must be coupled with prophylaxis





- 25 mg tds for 2 - 6 weeks



- 700 Gray single dose post operatively




A poor neurological recovery and spasticity associated with recurrence




Depends on site of ectopic bone



- posterolateral

- anterolateral

- medial


Elbow HO Excision PreopElbow HO Excision Post op






Nerve injury


Beware post operative instability


Elbow Post HO Excision



Olecranon Fracture



Intra-articular proximal ulna fracture




Articulates with trochlea

- may have a central bare area


Triceps insertion

- via broad aponeurosis which blends with anconeus and CEO




Non operative Management


Undisplaced fracture

- need to ensure triceps mechanism is intact

- Long arm POP 3/52 in 90o flexion


Operative Management




1.  Disruption of extensor mechanism

- any displaced fracture

2.  Articular incongruity






Excision fragment / triceps advancement


TBW Technique


Elbow Olecranon FractureOlecranon Fracture AP TBWOlecranon TBW Lateral



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



- bi-cortical K wires

- intra-medullary k wires

- intramedullary screw



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

- highly comminuted fractures

- oblique fractures

- best to use plate in these situations



- lateral decubitus over bolster

- curvilinear incision to avoid prominence of olecranon

- clean and washout haematoma

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

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

- drill hole in ulna, pass 20 gauge wire

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

- twist via 2 knots

- bury end of K wires under triceps


Screw / TBW


Beware bow of proximal ulna

- may cause medial shift

- avoid long screw




Olecranon Fracture Lateral



- fracture distal to centre of rotation


Main problem is hardware prominence

- precontoured low profile

- proximal hooks to grip triceps

- beware over compression articular surface in comminuted fractures


Olecranon Plate


Excision fragment / triceps advancement



- elderly

- osteoporotic

- < 50% articular surface

- non reconstructable








Relatively rare


Average age 50


Men 4:1 Women


Usually dominant arm





- associated with strenuous manual labour



- trauma


- synovial chondromatosis

- valgus extension overload / MCL insufficiency




Begins radiocapitellar joint


Progresses to ulnohumeral joint


Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses




Often have end range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge




May have well preserved radiocapitellar and ulnohumeral joints


Osteophytes olecranon and coronoid


Elbow OA LateralElbow OA AP




Useful in defining antomy pre operation / identification loose bodies


Elbow Arthritis CT


Elbow Loose Bodies CTElbow Loose Bodies CT 2




Useful in detecting early chondral damage


MRI Radiocapitellar OAMRI Ulna Trochlea OA




Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage




Inflammatory arthritis / RA

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion




Non operative







1.  Open procedures


A.  Open capsular releases

- for stiffness

- releases as required


See Elbow / Stiffness


B.  OK procedure

- removal of coronoid and olecranon osteophytes


See Elbow / Stiffness


2.  Arthroscopic Osteochondroplasty and Releases


Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection


Posterior joint

- remove loose bodies

- resect olecranon osteophytes


See Elbow / Arthroscopy


3.  Total elbow arthroplasty



- > 65

- sedentary




? reduced long term survival compared to RA


Bjord-Tilde et al J Should Elbow Surg 2009

- Norwegian Joint Registry

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

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


Posterolateral Rotatory Instability



Radius rotates externally in relation to the ulna

- posterior displacement of the radial head relative to the capitellum

- in flexion


Posterolateral rotatory Instability


Anatomy LCL


LCL Elbow




1.  Laxity or tear of ulna LCL

- posterior dislocation / subluxation / perching

- most common cause


2.  Torn CEO

- dynamic restraint


3.  Depressed fracture of radial head / malunion coronoid fractures

- leading to loss of secondary restraint




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





- acute LCL tear after dislocation



- tennis elbow release

- Kocher approach


Ligamentous laxity


Long standing cubitus varus




Posterolateral elbow pain


Describe clunk on full extension


Patient may be able to demonstrate instability




Test combines external rotation / supination with valgus and axial loading


1.  O'Driscoll Pivot Shift Test


Best with patient anaesthetised

- can sublux joint


If patient awake, only get pain and apprehension


Patient supine

- examiner at head of bed

- GHJ full flexed with hand over head

- elbow resembles knee in this position

- forearm supinated

- elbow fully extended


Valgus stress with axial load & slowly flex joint

- at 40o the radial head is subluxed maximally posterolaterally

- radial head becomes prominent as it dislocates

- patient feels apprehension as the radial head subluxes

- past 40o flexion the radial head reduces



- prominent radial head (dislocates)

- pivot

- pain  (apprehension)

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


2.  Table Top Test


Push up on table with forearms in supination

- radial head subluxes, patient has apprehension

- relieved by thumb pressing on radial head


Table Top Test 1Table Top Test BeforeTable Top Test After





Usually normal

- may be slight widening of radiohumeral joint

- radial head may appear slightly posterior




Difficult to distinguish lateral complex






Does not improve with time

- usually requires surgery if very symptomatic




1. Repair 

2. Imbricate

3. Reinforce/Reconstruct with PL graft




Kocher approach between Anconeus & ECU

- drill holes x 2 base sublime tubercle

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

- palmaris graft in figure of 8

- tighten with elbow at 30 - 40o of flexion


Post op

- hold flexed 2/52

- then allow ROM in hinged brace


Lateral Ligament Elbow Reconstruction




O'Driscoll et al JBJS Br 2005

- retrospective review of 44 cases

- some direct repair, some autograft reconstruction

- 86% satisfaction

- better outcomes in reconstruction group

Radial Head & Neck Fractures

Radial Head Fracture





- axial load with a valgus force




1.  Provides Valgus stability

- especially if MCL deficient


2.  Longitudinal stability

- aided by interosseous membrane


3.  Load Transfer

- 60% of load at elbow

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

- increase risk of OA


Hotchkiss modification of Mason Classification


Type I


Undisplaced fracture

- intra-articular displacement < 2mm

- no mechanical limit forearm rotation

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

- ensure no mechanical block to rotation


Radial Head Mason 1Radial Head Fracture Mason 1


Type II


Displacement > 2mm

- motion mechanically limited

- reconstructable


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


Type III


Severely comminuted fracture of the radial head and neck

- not reconstructable

- requires excision for movement


Type IV


Associated with elbow dislocation


Complicated Radial Head Fracture


1.  Elbow Dislocation


2.  Essex Lopresti


Fracture Radial Head + Disruption DRUJ / Interosseous membrane

- dorsal dislocation of DRUJ

- ORIF / replacement radial head

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


Surgical Options


1.  ORIF


Radial Head ORIF


Kocher approach

- between anconeus and ECU

- dissect muscles off capsule

- protect ulna collateral ligament under anterior edge of anconeus

- pronate forearm to protect PIN

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


Safe Zone for implants

- posterolateral portion of cartilage

- yellow and thinner

- non articulating

- 90o arc between radial styloid and lister's



- headless compression screws





- soft tissue stripping


Non union 

- same reasons

- 10%




Ring et al JBJS Am 2002

- results of ORIF Type III radial head

- overall 54% poor results

- good results with 2 or 3 fragments

- poor results with 4 results


2.  Excision



- elderly patient



- MCL or interosseous membrane disrupted



- reduced strength

- proximal radial translation

- DRUJ instability and pain

- valgus instability elbow

- arthrosis (deceased SA, increased contact stresses)


3.  Replacement


Radial Head Replacement LateralRadial Head Replacement APRadial Head Replacement Monoblock




1.  Silastic 

- less resistant to compressive forces

- can get synovitis

- good as temporary spacer

- can cut out later


2.  Titanium

- monoblock / modular / bipolar


Technique Modular Titanium Radial Head


Radial Head Replacement


Excise radial head

- insert trial broaches into neck

- small or large diameter, standard or long

- insert trial head size and thickness

- check xray

- ensure not overstuffed

- put through range

- prepare real implant on operating table

- have to insert head and neck as one piece


Radial Head Replacement Lysis APRadial Head Replacement Lysis Lateral




Grewal JBJS Am 2006

- modular radial head

- 26 patients followed prosectively for 2 years

- no revisions

- mild OA in 19%


Burhart et al J Should Elbow Surg 2010

- bipolar radial head

- 17 patients followed up for between 6 and 10 years

- 2 dislocations, 8 had evidence capitellar OA

- no loosening

- 16/17 good or excellent results Mayo elbow scores




1.  Aseptic loosening

2.  Overstuffing

3.  Capitellar OA

4.  Malpositioning


Radial Head Poorly Positioned


Radial neck fracture


Radial Neck Fracture


Indications for surgery

- > 30o angulated



- Z incision annular ligament

- elevate supinator with arm pronated




1. T plate in safe zone

- distal limit is bicipital tuberosity

- pre-contoured low profile plates

- may need to lag articular surface first

- check ROM intra-operatively

- plates often bulky and may limit ROM


Radial Neck Plate


2.  Fix with headless compression screws

- proximal to distal

- cross fracture site


Radial Neck Fracture ORIF Screws APRadial Neck Fracture ORIF Screws Lateral


3.  Retrograde Intramedullary Wire


4.  Radial Head Replacement

Rheumatoid Elbow

Elbow Rheumatoid ArthritisElbow Rheumatoid Arthritis 2




50% rheumatoid patients have elbow pathology

- 80% also have shoulder pathology

- 90% hand and wrist


Always consider entire upper limb





- swelling and pain

- may develop FFD due to holding in flexed position


Annular ligament may rupture

- anterior displacement of radial head

- due to pull of biceps


Collateral ligaments may rupture

- ML instability


Ulna nerve neuropathy

- synovitis

- rheumatoid nodule


Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction




Non Operative


SMART / DMART / Immunological medications






Turnbuckle braces

- night time

- for loss of extension




1.  Synovectomy +/- radial head excision



- minimal OA

- significant synovitis

- young patient


Radial head excision

- to improve rotation




Elbow instability

- can worsen

- may develop progressive valgus




1.  Open


A. Extended Kocher

- limited access to posterior olecranon

- limited access to medial side


B.  Universal Posterior approach


2.  Arthroscopic




Maenpaa et al J Shoulder Elbow Surg 2003

- 103 synovectomies open synovectomies via Kocker approach

- 5 year survival (reoperation / TER) 77%

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


2.  Arthrodesis / Resection arthroplasty


Salvage only


3.  Interposition arthroplasty


Results inferior to arthroplasty


4.  Arthroplasty


A.  Non constrained


Need ST stability and balancing

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

- good ROM

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


Ewald et al JBJS Am 1993

- 202 follow up for 6 years

- 1.5% revision 


B.  Constrained


Higher early rates of failure

- 22% 4 year revision rate


C.  Semi constrained


Morrey JBJS Am 1998

- Coonrad - Morrey prosthesis

- 97% minimally painful at 10 years



- anterior flange on humeral prosthesis very important to survival


Latitude prosthesis

- unconstrained can be converted to constrained


Total Elbow Replacement RA LatitudeTotal Elbow Replacement RA Latitude







Functional range


30- 130o - Flexion / Extension

50o each - Pronation / Supination





- skin / subcutaneous tissue

- capsule (anterior / posterior)

- collateral ligament contracture

- muscle contracture

- HO



- articular deformity / malunion

- articular adhesions

- impinging osteophytes (olecranon / coranoid)

- impinging fibrosis (olecranon / coranoid)

- loose bodies






Decreased flexion / extension

- ulno-humeral joint


Decreased pronation / supination

- radio-capitellar joint



- post-traumatic elbow stiffness is usually not painful

- indicates chondral damage




Active v passive ROM









- graduated active assisted stretching 


Dynamic hinged elbow splint 

- often poorly tolerated


Static progressive 

- turnbuckle splint


Operative Treatment





- not recommended

- may worsen stiffness

- due to haematoma or articular damage


1.  Arthroscopic Release

2.  Open Release

3.  OK Procedure

4.  Interposition arthroplasty

5.  Total Elbow Arthroplasty


1.  Arthroscopy 


Used increasingly to treat stiffness


Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO



- remove scar tissue / loose bodies

- remove olecranon / coronoid osteophytes

- radial head resection

- resect bony malunions

- can perform modified O-K procedure




Post elbow fracture malunion / posterior impingement / FFD 40o


Elbow Malunion LateralElbow Malunion MRI


Elbow Malunion ImpingementElbow Malunion Impingement


Elbow Malunion Partial DebridementElbow Malunion Post Debridement


Elbow Malunion PreopElbow Malunion Post Op


2.  Open Soft tissue releases 




Universal posterior approach

- arm over patient held by assistant


Lateral interval

- to distal humeral elevating BR and ECRL

- distally between ECRB and EDC


Medial interval

- find and protect ulna nerve

- between triceps and brachialis proximally

- detach pronator teres distally


Technique Morrey


A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus


B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule


C.  Excision of HO


D.  Removal of osteophytes

- coronoid / olecranon 


E.  Debridement of osteochondral flaps / loose bodies


F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable


G.  Radial head debridement / excision 

- especially if blocking supination / pronation




Increases of 30 - 40o


3.  OK procedure


Elbow OK Procedure APElbow OK Procedure Lateral




Outerbridge - Kashiwagi procedure

- debridement athroplasty




Posterior approach 

- triceps split


Excision of posterior capsule


Excision of tip of olecranon


Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- use burr

- need to minimise bone dust


Debridement of coranoid and radial head


Removal of loose bodies




4.  Interposition Arthroplasty



- stiff elbow joint

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

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




Kocher Approach


Detach lateral ligament from humerus


Refashion ulno-humeral surface

- may be necessary in fracture or extensive malunion 

- create congruent surfaces for flexion / extension


Strip of fascia lata 

- fashioned and attached to anterior humerus

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

- then doubled on itself and attached to anterior ulna

- articular surface is fascia on fascia


Lateral ligament is then reattached


+/- hinged external fixation with distraction


5.  Total elbow replacement (arthroplasty)



- 70% satisfaction

- less successful than RA

- some improvement in range (20o)





Compartment Syndromes

Upper limb fasciotomyForearm Fasciotomy Closure


1.  Antebrachial Compartment Syndrome




Supracondylar fracture of humerus

Both bone forearm fractures




Tense compartments

Pain +++

Passive extension of the digits or wrist increases pain

Paresthesias in median nerve distribution


Forearm Fasciotomy 


Decompression extending from elbow to wrist


Compartments (3)

- mobile wad

- volar

- dorsal



- medial arm

- across elbow

- continue as Henry approach into forearm

- can continue into palm as CTD incision



- lacertus fibrosus  (releases median nerve at elbow)

- fascia of forearm (releases superficial volar)

- deep fascial compartments (FCU / FDP / FPL)

- mobile wad


Remeasure dorsal compartment

- often decompression of volar compartment will reduce dorsal pressures




Volkmann's ischemic contracture

- result of delayed diagnosis

- severe muscle fibrosis & neuropathy 

- clawing of fingers


Muscles most commonly affected





- BR to FPL



Compartment Syndrome of Hand




Iatrogenic injuries

- arterial line or infiltration of IV medications

Crushing trauma

IV drug abuse

High pressure injections

- i.e. paint guns




Hand compartment syndromes lack abnormalities in sensory nerves

- no nerves are found within compartment

- non specific aching of the hand


Increased pain, loss of digital motion, continued swelling 

- tight swollen hand in a intrinsic minus position

- MP extension and PIP flexion

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


Pressure measurement 


Should have a lower threshold than in leg compartments 

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




10 separate osteofascial compartments 

- dorsal interossei (4) 

- palmar interossei (3) 

- adductor pollicis (1)

- thenar and hypothenar  (2)





- release thenar / hypothenar / adductor pollicis

- 2 x dorsal incisions over MC 2 and 4



Dupuytren's Disease


Definition Dupuytrens


Palmar Fibromatosis 




AD with variable penetration




Murrell's Theory of Pathogenesis


1. Microvascular ischaemia


2. Leads to conversion of 

- ATP to Hypoxanthine

- Endothelial Xanthine Hydrogenase to Xanthine Oxidase


3. Xanthine Oxidase converts Hypoxanthine to Uric Acid

- gives off OH-


4 OH- releases Free Radicals 

- stimulate fibroblast proliferation & increased Type III Collagen


5  Fibroblasts strangle microvessels

- Vicious Cycle  


Luck's three stages of Dupuytren's contracture 


1st stage (proliferative) stage 

- increased cellularity

- number of large myofibroblasts


2nd (involutional) stage 

- dense myofibroblast network aligned to long axis of collagen bundles

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


3rd (residual) stage 

- myofibroblasts disappear 

- fibrocytes are dominant cell type

- dense collagen cord remains




Cell of origin for the nodular myofibroblast is unknown 

- fibroblast / smooth muscle cell / pericyte

- Contractile cell

- nodules composed of myofibroblasts 

- No myofibroblasts in cords


Dupuytren's diathesis 


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

- usually have family history

- disease recurs rapidly following treatment


Feet (Ledderhose, 1897)

Penis (Peyronie) 

Garrod knuckle pads on dorsum PIPJs




Chronic alcoholism 

- ? metabolic effect on fat and prostaglandin metabolism


Diabetes mellitus 

- may be related to the diabetic microangiopathy



- likely effect of antiepileptic drugs on collagen metabolism




Chronic pulmonary disease


Occupational hand trauma 

- controversial 

- probably only aggravation due to traumatizing an early nodule




Age 50-70

Male 7:1



- especially celtics / vikings heritage

- rare in blacks & asians




A.  Involved anatomy


1.  Pre-tendinous Bands

- part of the palmar aponeurosis in palm

- common site of disease

- palpable nodule is pathognomonic of Dupuytren's


2.  Spiral Band

- continuation of pre-tendinous band into finger

- spirals deep to NV bundle then becomes superficial to bundle


3.  Natatory Ligament

- pass between the web spaces

- frequently diseased and prevents abduction


4.  Lateral Digital Sheet

- condensation of superficial fascia on either side of the finger

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


5.  Grayson's Ligaments

- hold skin during flexion and extension

- pass from fibrous tendon sheath to the lateral digital sheet

- volar to the NV bundle

- almost always involved in Dupuytren's


B.  Not involved anatomy


Skoog's fibres 

- transverse palmar fibres 

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

- the nerve is always deep to the fibres

- part of palmar aponeurosis

- deep to pre-tendinous band

- don't become diseased


Cleland's Ligaments

- hold skin during flexion and extension

- firm fascial structures 

- pass from the side of the phalanges to the skin

- dorsal to the neurovascular bundle

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


MEM: Dave Christie Goes Volar

(Dorsal Cleland's, Grayson's Volar)




LF / RF most commonly affected

MF / IF are sometimes affected

1st web sometimes affected




5 Major Pathological cords


1.  Pretendinous cord


In palm / other 4 in finger

- diseased pretendinous band

- causes MCPJ deformity


2.  Central cord 


Diseased central fibrofatty tissue

- large nodule often present in cord just proximal to PIPJ

- causes PIPJ deformity


3.  Spiral cord 


Pathological spiral band

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

- displaces neurovascular bundle volarly


Difficult to predict presence

- associated with more severe contractures


4. Lateral Cord 


Diseased lateral digital sheath

- intimately adherent to skin (sharp dissection required)

- contributes to DIPJ +/- PIPJ


5. Natatory Cord 


Diseased Natatory ligament

- causes web contracture


3 Minor Cords


1.  Retrovascular Cord 


Involves longitudinal fibers dorsal to the bundle

- commonly seen in combination with other cords

- causes DIPJ extension with lateral cord


2.  Abductor Digiti Minimi Cord 


Cord arises from abductor digiti minimi

- from MT junction 

- to ulnar side of the base of P2

- commonly adheres to the lateral skin


3.  Intercommissural Cords / 1st Web 


Pathological changes in 

- pre-tendinous band (radial longitudinal fiber)

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

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




1.  PIPJ Contracture 


4 components

- Central cord 

- Spiral cord 

- Lateral cord 

- Retrovascular cord


Correction sequence

- resection pathological cords

- capsulotomy, release check rein ligaments

- release of accessory collateral ligaments performed

- release of volar plate 


2.  MCPJ Contracture


Always correctable by removal of central band

- Flexion deformity does not lead to collateral shortening 


3.  DIPJ Hyperextension

Occurs in advanced disease

- contracture of retro-vascular + lateral cord




Usually mildly painful nodules to begin

- palm of RF and LF rays

- very short lived


Severe night pain

- suspect fibrosarcoma


Progressive contracture of MCP, then PIPJ

- nodule over PIPJ warning of impending PIPJ contracture


Difficulty putting hands in pockets

- difficult gripping

- poke themselves in the eye



- foot, penis




Nodules / dimples / pits

- palm, fingers





- DIPJ extension

- web space contractures / natatory cords


PIPJ Contracture

- Examine PIPJ with MCPJ flexed

- eliminate effect of cord

- establish if any joint contracture



- feet, Garrod's pads


Hueston Table Top Test

- Royal Melbourne hospital

- palm down on table

- positive if can slide pen under

- MCPJ contracture 30-40o





1. Significant functional impairment


2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30o

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


3. MCPJ contracture >30o


4. Trigger fingers

- must do limited fasciectomy 

- otherwise may get exacerbation


5. CTS 

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




Advanced RA

Trophic changes due to vascular insufficiency

Unfit for GA


Risk for Recurrence



- Garrod's pads highest risk

- foot and penis involvement

Family History

Bilateral / Radial and ulna involvement / multiple digits


Young patients and patients > 75





Partial Fasciectomy

Complete Fasciectomy

Dermatofasciectomy and STSG





Division of fascial cord

- Temporary method to relieve a severe MCPJ contracture

- not definitive therapy

- not in digits because high risk of neurovascular injury

- useful in elderly patients 

- results are better with dense mature cords 


Partial Fasciectomy


Dupuytrens surgery


Most common procedure


Recurrence rates of 50%

- need for repeat surgical procedure is only 15%




Longitudinal incision with Z plasty at end of case

- probably better with severe contracture as allows skin closure

- easier to protect NV bundles

- z at 60o


Careful flap elevation

- easy to button hole through skin


Dissection of NV bundles

- under then over spiral bands


Resection of diseased tissue


PIPJ  contracture > 30o


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

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


Skin gaps

- due to large contractures


- McCash open technique (secondary healing)



- let down tourniquet for haemostasis

- consider drain

- check finger vascularity




POP backslab in POSI

Wound check at 7 days

ROS 2 weeks

Night splint in extension for 3/12


Complete Fasciectomy 


Abandoned due high complication rate

- does not completely prevent recurrence of the disease


Dermatofasciectomy & FTSG



- recurrent disease

- young with diathesis / aggressive disease

- Recurrence under grafts very rare (Hueston)

- the FTSG as a fire break




Rarely necessary

- may be indicated if severe PIPJ flexion 

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

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


Adjunctive Procedures


Trigger Fingers 


Excise diseased fascia with release of the A1 pulley


Pulley release without local diseased fascial excision

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


Carpal Tunnel Syndrome 


Prophylactic CTD at time of fasciectomy is unwise

- accelerated scar formation may cause poor result


Partial Fasciectomy with CTD at later date





- can be a problem for the skin

- lead to necrosis


Vascular Impairment/ Flap Necrosis

- finger white at end of procedure

- often due to vessel stretched after significant release

- bend fingers, leave tourniquet down

- papaverine on vessels as antispasmodic

- warm hand

- inspect vessels for damage

- wait


Nerve Injury


Reflex sympathetic dystrophy 


Finger Fractures



1 / 1000 per year female

1.5 / 1000 per year male


Phalangeal fractures

- represent more than half of all hand fractures


Goals of Treatment


Restore normal function of the finger


1.  Restoration of bony anatomy


2.  Early motion

- inherent fracture stability

- splinting

- adequate internal fixation

- dynamic external fixation




Obvious swelling / bruising / deformity


Compound injuries


Rotational alignment

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

2.  Evidence digital overlap (see below)

3.  Plane of nail beds all in same plane

- LF often slightly different rotation


Finger MalrotationFinger rotation normal


Tendon avulsion




3 planes centred on MCPJ  middle finger

- AP

- lateral

- oblique


Care to look for subtle evidence joint subluxation


Principles Closed Treatment


POSI (Position of Safe Immobilisation)

- 20o wrist extension

- flexion of MCPJ to 60 - 70o

- IP joints in extension

- thumb in abduction


Acceptable alignment


Pun etal JBJS Am 1989

- 10o angulation in both planes

- no rotation

- 50% overlay


Surgical approaches


A.  Midaxial

- dorsal to NV bundle

- make dots on flexion creases with finger flexed

- this marks incision

- approach P1 by excision of one sagittal band

- less tendon disruption

- more difficult visualisation / access


B.  Midlateral

- volar to NV bundle


C.  Dorsal approach

- direct doral incision

- divide extensor hood over P1

- between lateral bands P2

- repair extensor mechanism at end

- risks scarring down of extensor tendon to implant


Types of injuries


1.  Extra-articular fractures


A.  Distal phalanx tuft fractures

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


2.  Joint injuries



- dislocations

- mallet

- Pilon fractures

- Flexor tendon avulsion           



- dorsal dislocations

- dorsal fracture dislocations

- volar dislocations

- Pilon fractures

- Condylar fractures


MCPJ dislocations


Tuft fractures


Most common hand injury

- usually crush mechanism



- trephination of subungal haematoma (relieves pain)

- repair nail bed disruption

- irrigation and washout of open injuries


Distal phalangeal shaft fractures


Distal Phalanx Fracture 1Distal Phalanx Fracture 2


Non displaced fractures

– splint DIPJ for 2-3 weeks



- higher energy fractures

- washout open wounds

- repair nail bed

- bony reduction with percutaneous K wire

- distal phalanx just under nail bed


Shaft fractures middle / proximal phalanges



- usually stable

- buddy strap 3-4 weeks


Finger Fracture Undisplaced




Finger Phalangeal Shaft FractureProximal Phalanx Shaft Fracture


Unstable fractures

- oblique, spiral, comminuted fractures


Transverse fractures P1 / characteristic deformity

- insertion of intrinsics at base PP flex fragment

- insertion of central slip to MP extend fragment


Finger Phalangeal Shaft Fracture Lateral


Fractures of P2 distal to insertion FDS / characteristic deformity

- FDS will flex fragment

- extensor tendon will extend fragment


Closed reduction

- relaxation of intrinsics

- axial traction

- reduction of deformity / POSI




A.  Transverse fractures

- cross K wire

- Lister’s intra-osseous wire fixation

- plating


Hand Phalange Circular WireFinger Cross K Wires


B.  Long oblique / spiral fractures



- fracture must be at lease 2 x diameter bone

- can treat with 2 x lag screws

- one perpedicular to fracture to lag

- one perpendicular to shaft to resist shear



- percutaneous K wires / screw fixation / plating


FInger Lag Screws


DIPJ Dislocations



- most common

- closed reduction with dorsal traction

- failed closed reduction – volar plate, FDP

- 60% injuries open

- splint joint in flexion 2- 3/52 weeks

- ROM at 1/52



- rare

- failed closed reduction – extensor tendon

- DIPJ extension splint 6-8/52


Mallet fractures


Mallet Finger



- axial load

- extensor tendon attached to bony fragment


Closed treatment

- mallet splint (Stack)

- expect 10o extensor lag with mild loss ROM

- good results with non – op management


Bony Mallet Thumb





- volar subluxation of distal phalanx

- fragment > 50% joint surface

- chronic > 12 weeks old


Open treatment

- high incidence of complications

- percutaneous K wire recommended



1.  Reduce and axial K wire

2.  Dorsal blocking K wire / axial K wire


Wehbe and Schneider JBJS Am 1984

- 21 patients with intra-articular fractures

- 15 treated non operatively

- 6 treated operatively

- nil improvement in outcome

- worsened surgical morbidity


Pilon fractures base distal phalanx


Impaction injuries



- ORIF very difficult

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

- fallback of arthrodesis / arthroplasty


FDP avulsions


Leddy and Packer classification

I   Vinculae are ruptured, tendon retracts to palm

II  Vinculae intact, tendon remains at PIPJ

III Large bony fragment, ensnared beyond A4 pulley


Type 1

- must be operated within 10 days to avoid contractures

- otherwise 2 stage reconstruction


Type 2 / 3

- can operate within 6 weeks

- ORIF large fragments


Condylar fractures of head of P1 / P2



- torsional and valgus impaction


London classification

Type 1  Unicondylar, undisplaced

Type 2  Unicondylar, displaced

Type 3  Bicondylar


Displaced unicondylar

- percutaneous K wire

- ORIF with screw


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


Open reduction

- P1 – between central slip and lateral band

- P2 – lateral to terminal extensor tendon

- must preserve collateral ligament which supplies blood


Type III bicondylar fractures

- difficult fractures

- 90 degree condylar plate

- lag screw and plate

- high risk of joint stiffness


PIPJ Dislocations



- Dorsal

- Lateral

- Volar




Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP


Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate


Volar plate

- thick distally

- thin proximally, allowing collapse during flexion


Dorsal dislocations PIPJ


Most common joint injury of the hand

- hinge joint permitting 110o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture



- hyperextension

- axial loading of the flexed fingertip



- dependant on integrity of the collateral ligaments

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

- unstable


Eaton Classification


I Simple hyperextension

- buddy strap, early ROM


II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10o further than instability

- each week extend further by 10o

- early aggressive ROM program


Dorsal Dislocation Simple


IIIA  fracture < 40% volar articular surface

- closed treatment with extension block


Finger Dorsal Dislocation Extension Blocking Splint


IIIB fracture > 40% + Pilon fractures

- inherently unstable

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

- aim for congruent articular surface and early ROM


PIPJ Dislocation and Large Bony Fragment


IIIB Treatment Options


1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty


Dorsal Blocking K wire



- flexion P2

- dorsal entry into P1

- 40o flexion

- early removal at 3/52

- Improvement compared to extension blocking


Suzuki / Slade Dynamic Distraction external fixator



- closed reduction through ligamentotaxis

- early motion of PIPJ



- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

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


Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation


Hotchkiss designed PIP compass hinge



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

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked


Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks


Volar plate arthroplasty / Volar plate advancement



- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52


Finger Volar Plate Arthroplasty


Volar PIPJ dislocations


Finger Volar DislocationFinger Post Volar Dislocation


A.  Straight volar dislocation


Assessment of central slip post reduction critical

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

- if nil active, surgical repair to prevent boutonniere


B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation


Lateral PIPJ dislocations


Rupture of one collateral ligament and volar plate

- may be bony avulsion



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

- can perform primary repair or reconstruct


MCPJ Dislocation



- volar plate not interposed

- MCPJ 90o hyper-extended

- reduce via wrist flexion and volar translation of PP

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

- extension blocking splint 3-4 weeks



- volar plate / lumbrical tendon / flexor tendons interposed

- joint space widened

- requires open reduction, dorsal or volar

- volar more direct but risk NV bundles

- protected motion post operatively


MCPJ Destruction



- infection

- trauma



- joint replacement

- fusion


MCPJ DestructionMCPJ Fusion APMCPJ Fusion Lateral


MCPJ Replacement

Finger Soft Tissue Injuries



DetippingDetipping xray




Distal to insertion of flexor and extensor tendons




Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum of skin


Nail complex


1.  Nail Plate


2.  Nail Bed

- adherent to thin periosteum of P3


A.  Proximal germinal matrix

- proximal part

- limit is semilunar lunula

- produces 90% thickness of nail plate


B.  Sterile matrix

- adherent to nail plate

- contributes little to thickness


3.  Paronychium

- surrounding skin on dorsum of fingertip


4.  Eponychium 

- covers nail plate proximally


5.  Hyponychium

- thick skin below distal edge of nail




A Oblique facing up

B Transverse

C Oblique facing down

D Oblique facing laterally


Tissue involved

- Pulp only

- Nail bed

- Bone




1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent Neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work


Management Pulp Loss


Pulp loss Finger




1.  Primary healing

- best option


2.  Secondary healing

- < 1 cm2 area to cover

- 90% 5 year satisfaction


3.  Skin grafting

- 50% 5 year satisfaction

- most are painful


4.  Flaps


Local flaps / VY flaps

- Atasoy single volar

- Kutlers lateral flaps


Regional Flaps

- Cross-finger

- Thenar flap


4.  Formalisation


If bone on view and patient doesn't want flap

- take bone to level distal to extensor / flexor tendons

- remove nail bed in full (bilateral eponychial incisions)


Bone on View




1.  Shorten and cover

2.  Preserve length and flap

3.  Secondary intention

- rarely a good option except in children


Soft tissue defects Finger


Local Flaps


1.  Atasoy  VY flap



- local



- often tender and sensitive long term

- can advance only 1 cm

- suitable for defects < 1 cm



- nibble bone back

- incise skin in V

- must release all fibrous septa form distal phalanx

- attempt to leave small vessels

- check is bleeding

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

- leaves too much tension on vessels


2.  Kutler's bilateral VY flap


Similar concept

- on both sides of digit


3.  Modified Kleinert flap


Lateral VY flap

- based on digital pedicle

- more volar VY flap than Kutler's


Regional Flaps


de-puplped finger injury



- 2 stage procedure 

- Often result in finger stiffness

- Contra-indicated if diabetes / vascular disorders

- age relative contra-indication > 40 years


1.  Cross finger flap


Rectangle of donor skin from dorsum of P2

- Hinge is mid-axial line

- Must preserve paratenon over extensor tendon


Full-thickness skin graft to donor site from forearm

- transversely across bicipital groove

- must remove all fat from FT graft


Graft sutured 75% onto dorsum of donor finger

- flap crossed onto distal finger pulp


Divide flap under GA 3 weeks later



- Obtain 10mm 2 point discrimination of flap


2.  Thenar flap



- source of good quality skin

- very similar to finger pulp

- 2 cm defect

- IF / MF / RF

- often difficult to oppose LF


Most important point is site of flap

- Position it high and parallel to MP crease

- If low or palmar can get debilitating donor site tenderness


Make skin 1.5 x defect size to reconstruct pulp

- donor site closed primarily or FTG


3.  Abdominal Flap


Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound


4.  Formalisation



B.  Soft Tissue Defects Thumb




1.  Moberg advancement Flap



- only for thumb

- Cover 2cm defect



- mid-axial incisions from injury site to MPJ

- entire volar skin flap with both NV bundles

- flex IPJ, suture

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


2.  Cross Finger Flap from Index Finger


3.  Littler Neurovascular Island flap


Ulna side of ring or little finger

- take on just one side

- significant secondary defect

- put a skin graft into secondary defect

- rarely first choice


3.  First dorsal Metacarpal Artery Flap



- skin over dorsum of P1 of IF

- 4-sided cut and mobilise on pedicle

- With art vein and nerve

- subcutaneous tunnel


4.  Free tissue transfer of great toe pulp


5.  Abdominal Flap


Gamekeeper's Thumb



Injury to ulnar collateral ligament of thumb MCPJ




Initial description

- chronic laxity of British gamekeeper's thumb's 

- no specific trauma

- secondary to breaking pheasant's neck


Acute trauma

- snow ski

- ball games


Valgus / forced abduction





- origin medial condyle metacarpal

- passes obliquely volarly 

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


Adductor aponeurosis 

- superficial to UCL

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid




Painful, swollen MCPJ


Tenderness along UCL


Abduction Stress Test

- in full extension and 30° 

- loss of end point or 30o > other side

- indicates complete rupture




3 types Bony avulsion


1. Small fragment pulled away from P1


Thumb Bony Gamekeepers


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


3. S-H III in paediatric population




Look for stenar lesion

- when distal end of UCL

- flipped superficially over adductor aponeurosis

- will not be able to heal


A.  Undisplaced


MRI UCL Proximal Undisplaced InjuryTorn UCL Minimally Displaced MRI


B.  Displaced UCL




Non operative



- partial tear

- undisplaced complete tear

- undisplaced bony fragment




6/52 thumb spica




Indications for surgery

- complete tear with stener lesion

- large or small displaced bony fragment

- SH III in paediatrics

- chronic injury


Displaced Complete tear / Stener Lesion



- 18 - 43%




1.   Interposition of the adductor aponeurosis

- between a completely avulsed proximal ulnar collateral ligament injury

- and the proximal phalanx ligament insertion site


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




Difficult clinically

- may be able to palpate displaced UCL






Dorsal incision along ulna border MCPJ

- Divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- Identify and repair UCL



- direct suture if able to

- bony anchors

- through drill holes and over lateral button

- cerclage wire


Post op

- 6/52 thumb spica


Gamekeepers Thumb Repair


Bony Avulsion


ORIF Indications

1.   > 25% articular surface

2.   Small avulsion fracture displaced > 5mm

3.   SH III


Chronic Injuries


1.  Dynamic tendon transfer 


Adductor pollicis

- release adductor pollicis from ulnar sesamoid

- attach to base P1


2.  Free tendon graft


Graft options

- palmaris longus

- fourth toe tendon



- figure of 8 through drill holes

- transverse drill hole base P1

- drill hole head MC

- 6/52 POP


3.  Static tendon transfer



- leave attached distally

- weave through drill holes


Hand Arthritis






CREST (scleroderma)


RA (rare form)

Other seronegative arthropathies


Reactive arthropathy





Finger Osteoarthritis

EpidemiologyHeberden's Nodes


Male & Females > 60 years

- X-ray evidence of OA



- 25% females

- 15% males


Affected joints


Base thumb

PIPJ / Bouchard's nodes

DIPJ / Heberden's nodes


Finger OA


3 Groups


1.  Heberden's nodes

2.  Basilar thumb & Heberden's 

3.  Heberden's and Bouchard's




Joint space narrowing

Subchondral sclerosis

Osteophyte formation











DIPJ Arthrodesis





- 15 - 20o flexion



- transverse incision over DIPJ / H

- split / divide extensor tendon

- resect with small bone cutters and nibbles




A.  Headless compression screw


DIPJ Fusion ScrewDIPJ Fusion Screw 2


B.  K wire and TBW

- single intra-axial K wire

- pass retrograde first, reduce, anterograde

- Circular wire

- small drill holes and pass 25 or 26 gauge wire

- tension


DIPJ FusionDIPJ Fusion TBW Lateral


PIPJ Arthrodesis


Best in RF / LF





- 25 - 35o



- 45 - 50o




Longitudinal incision




A.  Reflect central slip

- leave attached distally

- lateral bands remain 

- suture repair at end


B.  Interval between central slip and lateral band

- reflect central slip laterally


Release collateral ligaments

- leave volar plate intact

- create two opposable surfaces

- saw or bone nibbler




A.  Headless compression screw


B.  Crossed K wires


C.  Longitudinal K wire and TBW figure 8

- pass wire retrograde 

- reduce, pass distally into P2


PIPJ Fusion TBWPIPJ Fusion TBW 2




Fusion rates about 90%




See rheumatoid hand discussion



Inflammatory Arthritis












Absorption of distal tuft of phalanx





Scleroderma / Raynauds

Frost Bite





RA rarely







Similar hand appearances to RA

- no joint destruction even in setting gross deformity




Autoimmune disorder


Distension of joint from synovitis rather than destruction of joint


Pannus not as aggressive as RA




Migratory poly arthralgia

Flexor tenosynovitis

MP and PIP arthritis


AVN of carpus



- butterfly rash

- lymphadenopathy

- pleuritis / pericarditis / Glomerulonephritis

- haemolytic anaemias





Juxtacortical osteopenia

Subluxation / dislocation

Bone infarction and abnormal calcification


Joint destruction = Co-existent RA









Aimed at rebalancing soft tissues

- may be inadequate

- may have to resort to fusion






Hand Sclerodermad Scleroderma Occluded Superficial Palmar Arch


Autoimmune disease

Unknown aetiology

Small vessel disease

Fibrosis in multiple organ systems





- 40% patients have RF




Patients female and middle ages


CREST Syndrome


1. Calcinosis

2. Raynaud's

3. Esophageal Strictures

4. Sclerodactyly

5, Telangiectasia




Stiff shiny digits

Loss of creases

Acral tapering of digits

Autoamputation (acro-osteolysis)


Calcium nodules




Lung fibrosis





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

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




Joint erosion

- RA part of DDx


Resorption of thumb CMC

- subsequent radial subluxation of the thumb MC




Psoriatic arthritis




Autoimmune disease

- seronegative arthritis


5-10% of RA have psoriasis


DDx from RA


Asymmetrical distribution


Psoriatic rash

Nail changes / pitting


Often less aggressive

- typically DIPJ more involved

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




1.  Classic - involvement of DIPJ joints of hands

2.  Deforming - with ankylosis & arthritis mutilans

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

4.  Monarthritis

5.  Ankylosing Spondylitis - like


Hand X-ray


Periarticular phalangeal erosions

- asymmetrical

- no periarticular osteopenia


Periosteal new bone formation along MC / MT shafts



- typical 'Pencil in cup' deformity of DIPJ

- P3 tuft resorption & whittling


DIPJ Pencil in Cup


Juvenile Rheumatoid Arthritis


Differences from Adult RA


Usually much milder course

- 50-70% achieves remission


Deformity often opposite of Adult

- short ulna

- ulna hand / MC's

- radial deviation of fingers




Boutonniere deformity common

Intrinsic tightness uncommon


Extensor tenosynovitis signs uncommon

First sign is usually rupture of tendons with dropped wrist



Hand Infection



Human / Tooth Knuckle Injuries




Clenched knuckle

- tooth often penetrates capsule of MCPJ (60%)

- can injure the bone (58%)

- usually 3 / 4 th MCPJ


Associated Injury


Boxer's fracture

- 4th / 5th metacarpal head


Extensor tendon Laceration




Up to 50% rate of infection

- septic arthritis

- tenosynovitis

- osteomyelitis





- streptococci

- Staphylococci

- Eikenella

- anaerobes


Eikenella corrodens

- seen in 1/4 TKI

- gram negative rod / facultative anaerobe

- acts synergistically with strept and contributes to morbidity

- can be resistant to dicloxacillin

- usually sensitive to




Intial treatment

- povidone-iodine + copious irrigation



- augmentin oral

- IV penicillin



- best to debrige and washout all wounds

- open skin

- inspect extensor tendon

- open capsule, washout +++

- closure capusle

- leave skin open

- day 2 steristrip skin close


Await cultures

- change antibiotics accordingly



- failure of treatment with cephalosporin

- may be due to eikenella

- change to penicillin


Dog bites 




Mixed growth

- Streptococci

- Staphylocci

- Pasteurella




Washout & debride


TMP-SMX if allergic to penicillin


Cat Bites




More often become infected



- 50% Pasturella multocida




Incision and drainage



-  Augmentin / penicillin

- 2nd or 3rd generation Cephalosporin






Abscess of terminal pulp




Puncture wound

Paronychia or subungual abscess


S. aureus most common




Early Antibiotics and elevation


Usually requires incision and drainage



- lateral aspect of pulp

- unilateral longitudinal incision

- non-contact side of digit

- not too volar otherwise knocks out vessels

- must divide fibrous septa




Flexor Tendon Sheath Infections



S. aureus / Strept

- usually a history of trauma




IF / MF / RF

- extend from DP to distal crease



- extends to mid palm

- communicates with ulna bursa



- distal phalanx to volar wrist crease

- communicates with radial bursa




Kanavel's 4 signs


1.  Tenderness along course of flexor tendon

2.  Fusiform swelling

3.  Flexed attitude to finger

4.  Pain on passive extension of finger





- may settle with antibiotics if get early

- want improvement in 12 - 24 hours

- risk adhesions / tendon necrosis




Distal incision

- distal finger crease


Proximal incision

- distal palmar crease


Will see pus

- take swab for MCS


Pass infant feeding catheter

- into flexor sheath

- irrigate +++


IV ABx 48 hours


Occupational / hand therapy to prevent adhesions





Radial & Ulnar Bursal Infections


Bursal Anatomy


Enclose flexor tendons


Ulnar bursa is extension of little finger synovial sheath


Radial is extension of thumb synovial sheath


Coalesce in carpal tunnel to envelope all flexors

- 50% of time radial and ulna bursa communicate

- can get horse shoe collections


Deep Space Infections




Palmar pain and swelling


Dorsal pain and swelling




Midpalmar septum

- to MF Metacarpal


Hypothenar septum

- to LF Metacarpal


Potential Spaces

- thenar space

- midpalmar space


Thenar space

- ulnarly by midpalmar septum

- dorsally by Adductor Pollicis

- palmarly by index finger flexor tendon



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

- palmar incision


Midpalmar Space 

- Radial border midpalmar septum

- Ulnar hypothenar septum

- Dorsally 3-5 metacarpals

- palmar flexor tendons and lumbricals



- transverse incision across palm


Web Space Infection



- dorsally web skin

- Volar by transverse palmar fascia

- Radially and Ulnarly by fibrous septa



- both dorsal and volar incisions to ensure adequate drainage

- Avoid transverse incisions --> Contracture


Herpetic Whitlow




Cut on finger

- exposed to oral secretions




Often extremely painful




Oral antivirals

Recurrence 30 - 50%


Atypical Mycobacterium




Mycobacterium marinum

- aquatic trauma




Abundant tenosynovitis or joint synovitis


May take 8 weeks to culture on LJ medium





3-6 months ABx






Paronychia is skin around nail plate


Eponychia is skin covering base of nail plate




1.  Due to foreign material between nail plate and paronychium 


2.  By hang nail traumatising paronychium





- typically polymicrobial 

- aerobes and anaerobes

- Staph aureus, group A Strep, Eikinella corrodens

- Bacteroides, gram positive cocci and Fusobacterium nucleatum


Chronic paronychia

- atypical mycobacterium

- fungal infection

- gout

- carcinoma




Non operative

- warm soaks

- splinting 

- antibiotics (Augmentin)




Decompress and drainage of abscess may be necessary

- lift nail fold off plate +/- wedge resection

- avoid eponychial nail fold incision


Metacarpal Fractures



1.  Neck of 5th Metacarpal

2.  Metacarpal Shaft

3.  Metacarpal Head

4.  Base of Metacarpal Fracture Dislocations

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


1.  Neck of 5th Metacarpal Fracture


Non operative Management


Accept 45o angulation

- will have finger extensor lag, but will recover

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


Neck of Fifth Metacarpal Fracture


Operative Treatment



- K wire across MC head into 4th MC


2.  Metacarpal Shaft Fracture


Acceptable Deformity


Rotation < 5o

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

< 5 mm shortening


Metacarpal Fracture Minimally Displaced


Operative Management



- plate

- lag screws (if spiral fracture)

- intramedullary wires


Metacarpal Intramedullary Wires


3.  Metacarpal Head Fracture



- uncommon

- usually in index finger


Indication for surgery

- > 2mm angulation



- T plate

- headless compression screws / intra-articular


4.  Base of Metacarpal Fracture Dislocations


Can be missed

- may need CT to diagnose



- reduce joint closed +/- open 

- dorsal approach

- K wire


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


5.  Base of Thumb Metacarpal



A.  Bennett's

B.  Rolando

- Y shaped intra-articular


A.  Bennett's Fracture


Bennetts Fracture APBennetts Fracture LateralBennetts CT



- oblique intra-articular fracture

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

- metacarpal displaces proximally and dorsally due to APL

- inherently unstable



- closed reduction

- longitudinal traction on metacarpal

- use thumb to reduce metacarpal shaft

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

- 6 weeks in thumb spica cast


Bennetts FractureBennetts K wireBennetts ORIF


Bennett K wires


B.  Rolando Fracture



- 2 small intra-articular fragments

- poor prognosis


Operative management

- for significant displacement

- dorsal approach

- protect superficial radial nerves

- between APL / EPB and EPL

- attempt to anatomically reduce and fix with plate

Nail Bed Lacerations

Subungual haematoma 



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

- > 50% -> remove nail and repair bed


Nail bed lacerations


Complete nail bed injury




1.  > 50% nail lost

- will get hook nail

- ablate nail bed


2.  < 50 % nail lost

- repair bed under magnification

- 6.0 chromic cat gut

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


3.  Matrix defects

- can place nail bed material in place without sutures

- can use split thickness free nail bed graft

(i.e. from amputated digit)


4.  Proximal avulsion of nail plate

- always have germinal matrix laceration

- should always have 3 x horizontal mattress sutures




Hook Nail


Hook NailHook Nail



Replant 4 FingersReplant 4 fingers post





- reattachment of body part that has been completely severed


Revascularisation of incomplete Amputation

- vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results


Mechanism of injury






Indications - Urbaniak 1987



Multiple digits

Individual digit distal to FDS insertion

Partial hand / through palm


Almost any body part in child


Wrist or forearm


Above or below Elbow 

- only if sharply demarcated




Adult single digit proximal to FDS insertion

- poor results / stiffness


Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time


Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time


Severe crush or mangled



- through elbow

- high arm


Multiple level / segmental injury


Other serious injuries/diseases


Vessels atherosclerotic


Mentally unstable patient




Chinese red line sign 

- red streak along arterial course

- due to severe traction


Ribbon sign

- elongated tortuous arteries with pigtail appearance






Thumb has first priority

- a successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful


Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

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


Multiple amputations


Replant best digit to most useful stump

When thumb intact goal is to restore palm width


Single digit


Does well if FDS intact

- allows immediate mobilisation of digit


P1 replants


Useful function does not occur

- patient will bypass finger


Mid-palm amputations 


Absolute indication for replant 

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


Proximal injuries


Proximal forearm, EJ and Arm 

- usually avulsion types with extensive muscle injury

- infection and muscle necrosis very common 

- usually replant not indicated


Patient factors


High demand professionals 

- may push indications eg at P1


Age is not a barrier 


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


Premorbid conditions must be taken into account 

- DM, Smoking, HTN, peripheral vascular disease

- patient compliance




Key factor in success


Duration of allowed ischaemia varies from tissue to tissue


Recommended maximum


1.  Distal to carpus 

- 12 hours warm, 24 hours cool


Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

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

- when cooled replants have been performed at 36 hours


2.  Proximal to carpus 

- 6 hours warm, 12 hours cool


Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

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

- the deep muscle remains relatively warm

- the allowable 6 hours can't be extended


Transport of part

4oC ideal


2 Methods


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

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


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

- then putting on ice


No difference in outcome


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




Dedicated replant team


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


Operating theatre not the setting for practice


Surgical management


Operative Sequence for single digit


1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage


Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis




- longitudinal mid-lateral incisions for digital replants


Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1cm each side

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

- Shortening also helps with skin coverage


- K wire fusion DIPJ / P2


Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair


Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 



- 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise vein graft

- tourniquet acceptable

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

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

- papaverine antispasmodics

- 2 veins for every artery


Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft if not 

- use medial cutaneous nerve of forearm 



- skin closed under no tension

- digital incisions often left open to decompress repairs

- fasciotomies in larger replants

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


Replant at level of nail bed



- No dorsal veins 



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

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

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

4.   Medical grade leeches




Elevate gallows

- high dependency area

- high fluids

- anticoagulation controversial

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

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

- observations hourly for 72h then q4h

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



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


Reversal of failing patient


If appears threatened immediate action necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

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




80-85% survivability


Urbaniak 1985

- 51/55 survived

- ROM 82o distal to FDS

- 35o proximal to FDS


Ring Avulsions


Urbaniak Classification


I - circulation adequate

II - circulation inadequate

III - complete degloving / amputation


Major limb replantation




Amputations proximal to metacarpal level have significant muscle bulk

- to prevent myonecrosis immediate arterial inflow is necessary

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

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc

- return to OT at 72 hrs for inspection and DPC


2 most common causes of failure in major limb replants 


1.  Myonecrosis with subsequent infection


2.  Failure to adequately decompress the restored vessels


Rheumatoid Hand

Hand RA Exam

Screening of Joints



-  ROM



- behind head / to mouth

- to back pocket 



- flexion / extension elbows 

- pronation / supination with thumb up & elbows by side



- flexion / extension



- make fist with thumb in and out 

- spread fingers


Functional Assessment of Hand


Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch


1.  Tip to Tip Pinch Grip

- pick up coin 


2. Lateral pinch grip

- turn key


3. Precision grip

- write with pen


4.  Power Grip

- turn knob 


5.  Hook Grip

- hold suitcase / fingers


Look at Hands / Place on Pillow


Palms up



- CTD / flexor tendon synovectomy


- flexor sheath synovium

Thenar & Hypothenar eminences


Thumb up


Thenar wasting

Swan neck / Boutonniere deformity


Rheumatoid thumb Boutonneire


Palms down


Rheumatoid Hand



- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 



- ulna drift / replacement / synovitis

- tendon subluxation



- Swan neck / Boutonniere deformity

- rheumatoid nodules


Rheumatoid Nodules





- median nerve / CTS

- ulnar nerve




Extensor tendons

- drop fingers

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



- ruptures over Listers

- IPJ is extended by intrinsics also


Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering



- ? subluxed


Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes


Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes


Swan Neck Finger 1Rheumatoid Swan Neck Finger 1


Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

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

Management Summary

Rheumatoid Hands Xray


Rheumatoid Arthritis Diagnostic Criteria


1987 American College of Rheumatology 


Need 4/7 (MAX RANS)

1. Morning Stiffness

2. Arthritis of 3 areas > 6/52

3. Xray changes

4. Rh factor

5. Arthritis of Hand > 6/52

6. Nodules

7. Symmetric Arthritis > 6/52


Types of Surgery


5 basic Groups


1. Synovectomy / Capsulorrhaphy

2. Tenosynovectomy

3. Tendon surgery & soft tissue balancing

4. Arthroplasty

5. Arthrodesis


General Principles


Replace all MCPJs


Replace RF/LF PIPJs

Fuse DIPJs

Correct wrist deformity at same time or risk recurrence


Caput Ulnae Syndrome 



- volar subluxation of ulnar carpus 

- supination of carpus on wrist 

- apparent dorsal subluxation of distal ulna 


Nalebuff Classification MCPJ


Stage I - Synovitis

- medical Rx and splinting

- synovectomy


Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction


Stage III - Moderate joint destruction

- volar subluxation and ulnar drift

- soft tissue reconstruction possible

- arthroplasty gives more reliable results


Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases


Causes of MCPJ Deformity


Ulna Drift / Ulna Dislocation


1.  Physiological

- gravity

- lateral pinch pressure


2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)


3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

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

- volar / ulna carpal subluxation


Nalebuff Classification Thumb


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


Type I - Boutonniere

- the commonest

- MCPJ flexion, IPJ hyperextension


Type II - Boutonniere & Swan Neck


Type III - Swan Neck

- second most common

- deformity is at CMC / Dorsal & radial subluxation

- hyperextension MPJ / flexion IPJ


Type IV - Gamekeepers


Type V - Stretched Volar Plate MCPJ


Type VI - Arthritis Mutilans


Swan Neck





- terminal extensor tendon rupture or attenuated

- entrapped FDP



- volar capsule stretching / FDS rupture

- contracted central extenor slip



- intrinsic tightness 

- extrinsic weakness / MCPJ subluxation and subluxation extensor apparatus





- FDS tenodesis / Lateral band transfer

- DIPJ arthrodesis (mallet)


Intrinsic tightness

- above +

- intrinsic release


Fixed deformity

- PIPJ dorsal release

- then above



- arthrodesis (20/30/40/50)

- arthroplasty (LF / RF)


Boutonniere Finger



- rupture of central slip



- flexible - Matev's central slips reconstruction

- radial lateral band to central slip

- ulna lateral band to radial lateral band insertion


Rheumatoid Fingers

ConditionsBoutonniere Fingers


1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

- may get mallet

- arthrodesis

4.  Ankylosis

- arthrodesis / arthroplasty

5.  Unstable / flail

- arthrodesis usually best option

6.  Swan neck deformity

7.  Boutonnière deformity




Boutonnière deformity

- usually good function

- often don't need surgical treatment


Hand Boutonniere Finger


Swan Neck

- much more debilitating

- usually need treatment


Swan Neck Deformity (Intrinsic Plus Deformity)




Hyperextended PIPJ / MCPJ + DIPJ flexion

- Bunnell calls this "Intrinsic plus deformity"


Rheumatoid Boutonniere FingerRheumatoid Boutonniere Finger


Rheumatoid Finger Swan Neck XrayFinger Swan Neck




Primary process is usually synovitis

- starts at either MCPJ / PIPJ / DIPJ





- terminal tendon ruptured or attenuated



- may also be due to stuck FDP





- rupture of FDS due to synovitis

- volar capsule stretches due to synovitis 



- contracted central extensor slip





- relative shortening of long extensors



- relative intrinsic tightness

- also seen in CP / CVA



- destruction or deformity


Rheumatoid Swan Neck secondary to MCPJ


Nalebuff Classification


Function depends upon PIPJ flexion


Bunnell Test


Assess Interossei Tightness


Positive test 

- PIPJ flexion less in MCPJ extension than with MCPJ flexion

- interossei are tighter in extension

- invalidated by MCPJ dislocation



- hand dorsum up

- correct ulna deviation

- extend MCPJ & comment on active PIPJ range

- flex MCPJ & comment on active PIPJ range


Type I

- PIPJ passively correctable / regardless of MCPJ position

- Bunnell Test negative


Type II

- PIPJ flexion limited with extension of MCPJ

- Bunnell Test positive

- intrinsic tightness


Type III

- fixed PIPJ flexion regardless of MCPJ position 

- joint problem

- lateral bands dislocated dorsal to axis of rotation


Type IV

- joint destruction / X-ray arthritis


RA Swan Neck Fingers XrayRheumatoid PIPJ Destruction




Aim is to create FFD

- many techniques described


Type 1


A.  Create FFD by FDS tenodesis

- use slip of FDS

- detach proximally

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

- producing 20° FFD


+ DIPJ fusion


B.  Zancoli lateral band transfer


Lateral bands mobilised volar to axis of PIPJ

- raise flap of flexor retinaculum

- suture over lateral band to fix in place

- dorsal blocking splint / K wire


+ DIPJ fusion


Type II


Above +


Intrinsic release

- division of intrinsic oblique fibres



- oblique fibres which extend IPJ /  interossei

- transverse fibres flex the IPJ / lumbricals


Type III


PIPJ release first / Lateral band tenolysis / K wire

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

- manipulate joint to flexed position

- fix with K-wire

- often stiff due to flexor synovitis

- often need flexor sheath synovectomy to get moving


Type IV


Arthroplasty RF / LF for grasp 

- arthroplasty has highest failure rate for Swan Neck 

- high recurrence and poor range

- 80% survival at 9 years


Fusion IF / MF for strength 

- angle of fusion a cascade 

- 20 30 40 50 (IF MF RF LF)


Rheumatoid Fusion PIPJ LF RF


Boutonniere's Deformity (Intrinsic Minus Deformity)


Boutonnierre Finger 1Boutonnierre Finger 2




PIPJ flexed / DIPJ hyperextended /  MCPJ hyperextended


Often well tolerated & treatment not needed




1.  Central slip dysfunction

- always starts with PIPJ flexion 


2.  Lateral bands displace volar 

- secondary to triangular ligament stretching


3.  DIPJ hyperextends secondary to PIPJ flexion

- contracted oblique retinacular ligament

- becomes fixed

- examination finds limited DIPJ flexion with PIPJ in extended position


Nalebuff Classfication


Stage 1 

- mild extensor lag 10-15°

- passively correctable


Lateral band reconstruction

- reduce lateral bands dorsally

- suture together


Stage 2

- moderate 30-40° lag

- passively correctable


Lateral band reconstruction + Central slip shortening / reconstruction


Dorso-Medial Incision & Synovectomy

A. Reduce lateral bands dorsally & Suture together

B. Tenotomy Terminal slip

C. Central slip options

i)   Shorten 5 mm

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

iii) Reconstruct with PL

iv) Matev central slip reconstruction


Matev Central Slip Reconstruction

- radial lateral band divided at level of P2 

- proximal stump rerouted through central slip 

- attached to base P2 at central slip insertion

- ulnar lateral band divided distally

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


Stage 3 

- severe 

- fixed with x-ray arthritic changes


Arthrodesis / arthroplasty


PIPJ replacement


Rheumatoid Arthritis PIPJ OA




A. Pyrocarbon implants

- partially constrained press fit components

- relatively high failure rate

- can fracture when inserting and need cerclage wire


B.  Swanson spacer





Non reconstructable / irreparable

- extensor and flexor tendons

- collateral ligaments




Does not have same stability of MCPJ

- can dislocate




Dorsal incision

- straight or curved dorsomedially

- enter between central slip and lateral band

- can detach central slip proximally and reflect distally 


Release contractures

- balance soft tissues

- retain collaterals


Broach distally and proximally

- avoid extension at all times


Implant must achieve full extension

- no buckling, and no impingement


Repair central slip


Post op

- immobilise for 1 week

- dynamic extension splint 0 - 30o (Capner)

- active flexion


Arthrodesis PIPJ


Approach as above

- resect collaterals

- position as appropriate

- cross K wires / screw

Rheumatoid MCPJ



Ulna drift & volar dislocation


Rheumatoid MCPJRheumatoid MCPJ Ulnar Deviation


Causes of MCPJ Deformity


Ulna Drift / Ulna Dislocation


1.  Physiological

- gravity

- lateral pinch pressure

- power grip


2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)


3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

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

- volar / ulna carpal subluxation


Nalebuff Classification MCPJ


Stage I - Synovitis

- medical treatment and splinting

- synovectomy


Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction


Stage III - Moderate joint destruction / Volar subluxation

- soft tissue reconstruction possible

- arthroplasty gives more reliable results


Rheumatoid Dislocated MCPJRheumatoid Dislocated MCPJ


Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases




Stage I Synovectomy MCPJ



- marked synovial proliferation not responding to medical treatment

- 6/12 non-operative

- painful

- concern regarding progression to deformity



- joint destruction with articular erosion

- instability

- fixed deformity or dislocation



- incise hood on Ulna side extensor tendon

- make sure clear under volar plate & collaterals


Stage II Synovitis / Ulna Deviation / Preserved MCPJ  


Synovectomy + Soft Tissue Reconstruction


1.  Ulna side release 

- divide transverse, oblique & sagittal bands


2.  Crossed Intrinsic Transfer

- corrects ulna drift

- ulna side intrinsics are released 

- transferred to the Ulna neighbour radial intrinsics

- reinsert through radial lateral band

- use EI for Index attach to radial side

- release EDM at little


3.  Extensor Tendon Relocation

- ulna sagittal band release

- radial sagittal band tightening


Stage III / IV Destroyed MCPJ


RA MCPJ Arthritis


Arthroplasty + ST Reconstruction as above


Swanson Joint Replacement


Swanson's Indications

- fixed or stiff MCPJs

- x-ray shows destruction or subluxation

- ulnar drift not reconstructable

- contracted intrinsic and extrinsics

- associated stiff IPJs


Swanson's contraindications

- infection

- inadequate skin coverage

- poor NV status

- irreparable intrinsic/extrinsic system

- insufficient bone stock



- painless joint with useful arc of motion





- usually > 40°

- get about 10° improvement



- > 80% pain relief

- no increase in strength


Deformity correction

- up to 40% loss over time

- loss of correction often due to inadequate soft tissue balancing



- 90% 10 year survival

- silicon synovitis uncommon unlike for wrist or trapezial implants


Technique MCPJ Swanson Arthroplasty



- transverse incision dorsum

- full thickness flaps preserving dorsal veins 



- incise extensor hood on ulna aspect each joint

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

- incise and remove capsule and synovitis


MC head

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

- with final cut at 90° to shaft

- this often means removing collaterals

- ream MC with awl or drill



- do not resect P1 base

- just ream with awl



- resection of bone should allow no buckling of implant 

- no impingement of MC on P1

- insert prosthesis proximal then distally

- should have passive motion of 90°


Soft tissue balancing

- ulnar intrinsic release

- crossed intrinsic transfer

- extensor tendon relocation






Rheumatoid Thumb

Nalebuff Classification


Type I - Boutonniere 

- commonest

- MP flexion /  IP hyperextension

- usually EPB rupture with EPL subluxation


Rheumatoid Boutonniere Thumb


Type II

- Boutonniere & Swan Neck

- doesn't exist according to Nalebuff


Type III - Swan Neck

- second most common

- primary deformity is OA and dorsal subluxation of CMC

- hyperextension MPJ / IPJ flex


Rheumatoid Thumb Swan Neck


Type IV - Gamekeepers

- due to MCPJ synovitis

- stretches UCL

- either synovectomy / UCL reconstruction

- or fusion


Rheumatoid Gamekeepers Thumb


Type V - Stretched Volar Plate MCPJ

- differentiated from Swan Neck by no CMC disease

- fusion of MCPJ


Type VI - Arthritis Mutilans

- destruction and instability MCPJ / IPJ

- arthrodesis only option


RA Thumb Destruction IPJ


Boutonniere Deformity


RA Thumb Boutonniere's




Synovitis of MCPJ

- extensor Hood stretched

- EPB ruptures

- EPL tendon displaced Ulnarward & Volarly

- becomes flexor 




1.  Flexible MCPJ


A.  Synovectomy of MCPJ


B.  EI to EPB / EPL Centralisation


C.  EPL transfer + fusion IPJ

- divide EPL over P2 and reattach to base P1

- good correction early 

- but 66% recurrence


2.  Fixed MCPJ / Flexible IPJ


Arthrodesis / Arthroplasty MCPJ

- arthrodesis better suited for young, high demand

- arthroplasty better suited to low demand


Rheumatoid MCPJ Fusion


3.   Fixed IPJ and MPCPJ


A.  Fuse both 

- best option 


B.  IPJ fusion / MCPJ arthroplasty

- with arthroplasty have to balance soft tissues

- reroute EPL as above


Swan Neck




RA Thumb Swan NeckRA Swan Neck Deformity


Disease at CMCJ

- leads to dorsal subluxation of CMCJ 

- beak ligament is not functional

- result is adduction contracture


MCPJ hyperextension

- ? volar plate stretches


IJP flexion

- ? Mallet rupture 




A.  Trapeziectomy and LRTI


Rheumatoid Swan Thumb Trapeziectomy


B.  +/- MCPJ fusion


Thumb MCPJ Fusion


Tendon Injuries

Extensor Tendon Injuries




II Middle Phalanx


IV Proximal Phalanx


VI Metacarpal

VII Dorsal Wrist Retinaculum

VIII Distal Forearm

IX Mid & Proximal Forearm


MRI Wrist Extensor Compartments




Sagittal bands

- stabilise EDC

- extend MCPJ


Lateral bands

- lumbricals extended PIPJ


Zone 1 Mallet Finger



- loss of extension of DIPJ

- +/- Swan neck deformity

- hyperextension of PIPJ due to unopposed central slip action 




Avascular region of tendon at insertion into DIPJ

- explains poor surgical results






1.  Forced flexion of extended digit

- Rupture of tendon

- Avulsion of tendon ± small fragment of bone


2.  Forced hyperextension of DIPJ

- fracture of dorsal base of P3



- Laceration over dorsum of DIPJ




Type I    

- closed trauma

- no bone or < 1/3


Type II  

- laceration


Type III  

- deep abrasion


Type IV  

A) Transepiphyseal plate fracture in children

B) > 1/3 of joint surface

C) > 1/3 + Volar Subluxation of P3




1.  No or small Bony Lesion


Extension splint (Stack splint) for 6 to 8 weeks

- night splinting further 6 weeks

- 80% good results if treated early

- direct repair should be avoided (poor blood)


2.  Bony lesion > 50% with volar subluxation


A.  Extension splint


- poor skin, high risk of breakdown

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


3.  Chronic Mallet Finger 


1.  Arthrodesis 

- joint incongruent, arthritic or fixed


2.  Reconstruction possible if supple


4.  Open


Suture skin and tendon together


Zone 3 Boutonniere Lesion



- disruption of central slip at PIPJ





- forced flexion of PIPJ

- causes avulsion of central slip ± bony fragment



- laceration over central slip

- similar progressive deformity




Deformity usually not present at time of injury

- develops after 2-3/52


1. Flexion of PIPJ

- due to loss of central slip

- unopposed action of FDS


2. Stretching of expansion between central & lateral slips 

- transverse retinacular / triangular ligaments


3. Lateral bands migrate volar

- position volar to axis of rotation


4. Pull of lateral bands exclusively directed to DIPJ

- DIPJ hyperextends


5. MCPJ also hyperextends because of pull of long extensor




1.  Hold wrist and MCPJ fully flexed

- relaxes lateral bands

- unable to actively extend PIPJ


2.  Elson's test

- flex PIPJ to 90o over edge of table

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






1.   Splint PIP in Extension 4/52

- Leave DIPJ free and allow ROM


2.  Capener Splint 4/52



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

- ff close to insertion, pull-out suture used

- PIPJ splinted in full extension for 6/52

- replaced with Capener splint when wound healed & sutures removed




Palmaris longus weave


Extensor Tendon Repairs Zone 5 - 9




Excellent results of repair 5 proximal zones

Only 50% excellent results 4 distal zones




Lacerations >50% zones V-VIII should be repaired

- modified Bunnell or Kessler best

- try to maintain length


Dynamic splinting 


Greatly improves results and is key 

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

- typical repairs shorten tendon


Outrigger with passive extension by rubber bands

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

- allow 5mm excursion of tendon



Flexor Pulley Ruptures



5 Annular pulleys

3 Cruciate pulleys




A1 and A5 expendable


Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3




Rock climbers

- usually when slipping


May hear or feel a pop


Develop swelling / tenderness / pain



- usually only with multiple pulley rupture





- exclude fracture



- very good



- if US inconclusive




Grade 1

- strain

- A4 tear (has good prognosis)


Grade 2

- partial tear A2 or A3


Grade 3

- complete A2 or A3 rupture


Grade 4

- multiple pulley rupture

- +/- lumbrical avulsion or collateral ligament damage




Non operative


Single complete pulley ruptures

- no climbing for 6 weeks

- gradual return to climbing with pulley taping

- full return to sport at 3 months




Multiple pulley ruptures

- repair techniques poor

- reconstruction required

- A2 with palmaris longus graft

- A3 with extensor retinaculum graft




Flexor Tendon Background



Fascicles of long, spiraling bundles

- tenocytes & Type I collagen

- synovial cells & fibroblasts present



- surrounds the individual collagen bundles



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

- contains most of the blood vessels & capillaries



- thin visceral layer of adventitia on tendon

- provides nutrition & allows gliding


Synovial Sheaths

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

- parietal layer continuous with the pulleys

- tendons attached via long & short vinculae




Thickenings of the synovial sheath

- 5 strong annular pulleys interposed by 3 collapsible cruciate pulleys 

- allow the annular pulleys to approximate in flexion


A2 & A4 

- fibro-osseous annular pulleys

- arise from periosteum of the phalanx

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

- most important


A1, A3, A5 

- arise from the volar plates 

- MCPJ, PIPJ & DIPJ respectively


Palmar Aponeurosis Pulley 

- important additional pulley

- transverse fibres of palmar fascia


Thumb Pulleys

- A1 (MCPJ) and A2 (IPJ)

- Oblique pulley in between and is most important

- can be excised if A1 intact


Flexor Tendons


Excursion can exceed 8cm

- in pulley area flexor tendons have segments that are avascular  





- arises from single muscle belly

- volar aspect of humerus, radius and ulna

- separates into 4 tendons in forearm

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

- LF may be absent (20%)

- bifurcates at level A1 pulley

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



- has independent action

- FDS & interossei combine for forceful flexion

- 200N achieved in power grip



- has common muscle origin

- arises volar aspect ulna and interosseous membrane

- deep to FDS

- several digits have simultaneous action

- acts as primary digital flexor 



- arise from FDP

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

- insert on radial side of extensor expansion

- flex MCPJ and extend IPJ's


Vascular Supply


Blood vessels


1. Longitudinal vessels enter tendons in palm

-  Vessels enter at proximal synovial fold in distal palm


2. Vessels enter at osseous insertions


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

- VBP vinculae brevis profundus 

- VLP vinculae longus profundus

- VBS vinculae brevis superficialis 

- VLS vinculae longus superficialis


Flexor tendons have highest vascularity dorsally


Synovial Fluid Diffusion


May function better than vascular perfusion

- composition similar to joint fluid

- imbibition process

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

- synovial sheath is critical to this process

- lacerations disrupt this mechanism


Avascular segments


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


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


Tendon Biochemical Composition 



- Type I collagen 95%

- Type III & V collagen 5%


Dense, parallel collagen fibres

- Highest tensile strength of all soft tissues 

- Collagen in triple helix of tropocollagen molecules 


Age and immobilization

- increases collagen content 

- loss of water content, glycosaminoglycan concentration & strength


Exercise training

- increases collagen fibril size

- increases strength & stiffness


Tendon Healing  


Both Intrinsic & Extrinsic factors

- extrinsic - fibroblasts and inflammatory cells from periphery

- intrinsic - fibroblasts and inflammatory cells from epitenon


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


3 Phases

- inflammatory

- fibroblastic

- remodelling


Inflammatory Phase Day 1-4


Clot fills defect

- Epitenon cells migrate into & bridge the gap

- Peritendinous cells proliferate & migrate into laceration site


Fibroblastic Phase Day 5-28


Collagen secretion begins by day 5

- fibres formed in random fashion

- Fibroblasts become the predominant cell type

- Synovium is reconstituted by day 21 

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

- Increased strength by 2 - 3 weeks

- Collagen content increases for first 4 weeks

- Collagen reorientation complete by day 28


Remodelling Phase Day 28-112


By day 28 fibroblasts longitudinally oriented 

- progressive remodeling & realignment of collagen fibrils

- By 6 weeks gap is completely filled

- By 8 weeks collagen is mature & realigned


By 4 months

- maturation complete 

- fibroblasts now quiescent tenocytes

- Full tensile strength only reached after physiologic loading




Dense adhesive scar 

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


More severe 

- immobilized tendons

- increased severity of synovial sheath injury /crush

- gaps > 3mm





Flexor Tendon Complications



1.  Flexor Tendon Rupture

2.  Adhesions

3.  PIPJ contractures

4.  Triggering

5.  Pulley failure

6.  Quadrigia


1.  Flexor Tendon Repair Rupture






Management Options


FDS only

- usually minimal impairment


FDP only

- may be better to fuse DIPJ

- passing tendon through FDS may give poor result



- repair / graft FDP


One Stage repair



1. Minimal scarring

2. Pliable joints

3. Adequate retinacular pulley system

4. Not Zone 2


2 Stage repair  




1.  Severe adhesions or scarred tendon bed

2.  Contractures

3.  Disruption of pulley system

4.  Missed injuries

5.  Injuries not suitable for primary repair

- usually gross contamination


Technique 2 Stage



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


Technique Stage 1 


Long Brunner incision finger

- Scarred tendon remnants excised, contractures released 

- A2/4 pulleys reconstructed if necessary

- Silastic implant sutured distally to FDP Zone 1

- proximal end zone 5 free

- need incision in palm to pass through to forearm 


Mobilisation regime post-op

- get finger moving / passive exercises +++

- minimise adhesions

- recreate synovial sheath for second stage


Pulley reconstruction

- use FDS, extensor retinaculum, PL free tendon

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

- A4: superficial to extensor tendons


Technique Stage 2 


Graft options

- Palmaris longus (absent 25%)

- Plantaris (absent 20%)

- Long toe extensor (IV)



- performed at 3 months 

- Early, protected Post-op mobilisation

- active motion at 4 weeks


2.  Flexor Tenolysis


Diagnosis Flexor Tendon Adhesions


Limited active ROM > passive ROM

- tendon adhesions


Limited passive ROM = active ROM

- joint contracture


If there is a marked difference between active and passive ROM

- adhesions likely but

- need to ensure repair is intact

- feel for tendon / ultrasound




Up to 20% of patients require tenolysis

- therapy +++ for 3 - 6 months

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

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




Must be prepared to go on to 2-stage repair

- long brunner incision

- access tendon through sheath via less important pulleys

- early active ROM critical


3.  PIPJ Contractures


Non Operative



- static night time extension splints

- dynamic external fixators






Access between A2 and A3 pulley

- remove cruciform pulleys

- flexor tenolysis

- release check rein ligaments

- release accessory collateral / collaterals / volar plate





Improve extension 20 - 30o

- lose equivalent amount of flexion

- change functional arc


4.  Triggering


May be triggering on A2 or A4 pulley

- Non operative treatment


5.  Pulley Failure and Bowstringing


6.  Quadriga




FDP of MF / RF / LF linked

- will only extend as much as of shortest tendon

- if limited excursion of one FDP due to repair etc

- present with limitation of all finger flexion




Release adhesions of the shortened tendon



Flexor Tendon Repair



1. Core suture


Strength of repair proportional to

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

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


2. Repair strength increases more rapidly with early motion stress


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


4. Repairs usually rupture at knots


5. Locking loops decrease pull out and increase strength


7. Peripheral Circumferential Suture 

- increases repair strength by 10-50%

- reduces gapping and bulk of repair significantly

- closure of epitenon with 6/0 suture


Partial Tendon Lacerations


< 25%

- debride


25 - 25%

- epitenon repair


> 50%

- core and epitenon repair


Early ROM Rehabilitation


1.  Load at failure at 3 weeks 

- immediately mobilised tendons 3 x > immobilised tendons

- more rapid collagen realignment

- histological exam increased healing response with decreased scar response


2.  Early mobilization decreases adhesions


Early Active ROM Protocol 


Position in extension blocking splint

- wrist and MCPJ flexed

- DIPJ and PIPJ in extension


Stage 1

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

- active extension of finger in splint

- splint never removed


Stage 2

- once full passive motion gained (each hour)

- 5 x passive finger flexion & active extension

- 5 x active finger flexion & 5 active finger extension

- splint never removed


6 Weeks

- splint removed & active wrist movement

- no resistance


8 weeks 

- resistive work (sponge squeezing)


12 Weeks 

- normal activity




Brunner incisions

- incorporate laceration

- avoid sharp angles <60o

- longitudinal incisions over flexor creases avoided


Identify and protect NV bundles


Expose synovial sheath

- preserve A2 and A4

- can remove other pulleys


Zones of Injury


Zone 1 

- distal to FDS (FDP only)


Zone 2 

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


Zone 3 

- in palm, lumbrical origin


Zone 4 

- in carpal tunnel


Zone 5 

- proximal to carpal tunnel




Zone 1




1.  Open / laceration


2.  Rugger jersey finger

- most common RF

- caught in jersey whilst grasping

- RF forcibly extended at DIPJ while FDP is contracting maximally

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




Avulsion FDP Type 1

- FDP retracts into palm

- vinculum ruptured

- tender swelling in palm 

- may need separate palmar incision

- need to pass under A2 and A4 pulley

- suture tendon to paediatric feeding catheter

- must be repaired in 7-10 days


Avulsion FDP Type 2 

- most common type

- retracts to PIPJ level

- vinculum intact

- swelling at PIPJ level

- early reinsertion best

- can be repaired up to 3 months after injury 

- may progress to type 1 injury if vinculae give way


Avulsion FDP Type 3 

- large bony fragment

- A4 pulley catches fragment & prevents retraction

- early reattachment




1.  Tendon to tendon repair

- if possible


2.  Insufficient distal tendon

- prepare bony insertion

- modified Kessler into tendon

- pass suture ends through distal phalanx and nail plate

- tie over button

- use 4.0 monofilament i.e. prolene

- need to remove button and sutures at 8/52


3.  Bony avulsion

- ORIF / button repair


Zone 2 / Bunnell No Man's Land



- both tendons injured

- high risk of bulky repairs / adhesions / poor function




Tendon laceration

- usually distal to skin cut

- need to retrieve tendons from palm

- A2 & A4 pulleys need preservation

- FDS & FDP both repaired if possible

- may only need one limb of FDS


Core Suture

- 2 x modified Kessler

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

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


Peripheral suture

- 6.0 prolene running suture

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

- very important for strength and allowing smooth glide


Zone 3


Delayed repair up to 3 weeks possible 

- lumbrical holds tendon 

- relatively good prognosis


Zone 4


Rigid compartment

- good result more difficult to achieve

- often complicated by median nerve injury

- should repair within 3 weeks to avoid myostatic muscle contraction


Zone 5 


Loose compartment

- good prognosis but associated nerve injuries important prognostically

- quality of repair not so important

- should repair within 3 weeks otherwise muscle contraction occurs






Thumb Radial Collateral Ligament

DefinitionRadial Collateral Ligament Avulsion


Also known as Chauffeur's Thumb




Much less common than UCL injuries




Rarely get soft tissue interposition




Chronic Instability


1.  Repair scarred ligament


2.  Reconstruct with graft


3.  Advance Abductor pollicis

- reinsert 10mm more distally on P1



Tumours of the Hand




Most common bony tumour of hand


Risk malignant transformation isolated lesion is < 2%

- more likely in long bones than hands




Proximal phalanx > middle





- multiple enchondromatosis

- risk of transformation 10 - 25%



- enchondromas and hemangiomas

- risk transformation close to 100%




Observation unless

- pain

- aggressive X-ray changes

- increased uptake on bone scan


Biopsy to exclude malignancy


Pathological fracture


Allow fracture to heal

- enchondroma does not resolve


Curette and bone graft at a later date


Epidermal Inclusion Cyst



Most frequent tumour around distal phalanx


M>F 2:1


Mean age 3rd decade




Likely traumatic 

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




Painless firm swellings

Most common volar aspect P3 index / middle




Round / oval lesion in P3

- thinning of cortex


Epidermal Inclusion Cyst




Fibrous capsule with keratin filled space

Squamous epithelium




Foreign Body Granuloma




Curettage and bone grafting (if bony)


Excision of lump

- recurrence very unusual







Most common tumour of hand

F > M

2nd - 4th decade







Mucoid degeneration of collagen tissue

Synovial herniation




1.  Dorsal

- scapho-lunate ligament 

- radial to EDC


2. Dorsal



3.  Volar

- scapho-trapezial joint 

- between FCR and APL


4. Retinacular

- along flexor sheaths 

- A1 / A2 pulley


5. Mucoid cyst

- associated with DIPJ OA and osteophyte


Recurrence rate


Dorsal 5%


Volar 20%




Most asymptomatic

- soft to firm

- 1-3 cm

- transilluminate


Mucoid cyst can groove nail bed

- important to remove osteophyte as well to prevent recurrence


McKeon J Hand Surg Am 2013

- association with ligamentous laxity and positive scaphoid shift test





- cavity lined by epithelium

- viscous mucin

- hyaluronic acid




Non - operative


Aspiration + HCLA injection

- usually needs multiple attempts


Khan J Hand Micosurg 2011

- aspiration plus steroid sucessful in 60%




Excision of ganglion

- find neck and dissect down to capsule

- remove capsular window


1.  Open Dorsal SLL



- radial side EDC

- protect SRN

- follow down

- excise neck and capsule




Edwards J Hand Surg Am 2009

- arthroscopic excision in 55 patients

- no recurrence


Kang J Hand Surg Am 2008

- RCT of 72 patients

- open v arthroscopic

- recurrence in 3/28 in arthroscopic

- recurrence in 2/23 in open


2.  Open Volar STJ



- between FCR and radial artery

- protect palmar branch median nerve





Nerve injury


Tendon damage


Giant cell tumour of tendon sheath



Benign tumour that arises from synovial tissues

- found near synovial-lined tendon sheaths


? Localised PVNS




2nd most common tumour of the hand


Age 40 - 60




Unknown origin

- theorized to be localized form PVNS

- similar histology

- however, lacks the inflammatory component of PVS 

- is considered by most to be a benign neoplasm

- may be a reactive process to minor trauma




Usually found near flexor tendons of hands & feet

- painless, firm and multi-lobulated mass

- usually on volar surface of finger


May present with

- lump

- loss of function




Can cause bone invasion and remodelling




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






Arise from synovial tissue

1. Well-circumscribed & discrete

2. Nodular & encapsulated


Doesn't invade surrounding tissues


Diagnostic colour

- yellow (cholesterol)

- brown (haemosiderin)

- grey (fibrous tissue)




Giant cell tumours prominent

- hyalinised CT

- sheets of round, oval & spindle cells

- focal collections of foam cells - xanthoma cells

- scattered haemosiderin




Marginal excision + bone currettage


Recurrence rate

- 10% - 20%

- to due to incomplete excision or spillage

- higher with bony involvement








Glomus Tumour







Hypertrophied glomus 

- coiled AV structure involved in temperature regulation

- > 50% in subungual region

- hand is the most common site

- usually under the nail plate





- pain

- exquisite tenderness

- cold intolerance




Ridging of nail bed

Blue spot at base of nail




Well defined radiolucent eccentric lesion

- base of P3

- < 1cm




Dark on T1 / Bright on T2




Remove nail plate

Longitudinal incision in nail bed

Excise tumour and repair nail bed

Replace nail







3rd - 6th decade




More frequent proximal


Most frequent

- thenar eminence 

- proximal phalanx




Non tender, mobile, soft


Does not transilluminate




Radiolucent on X ray

- Bufolini's sign




Negligible recurrence rate


Other Hand Tumours

1.  Foreign Body Granuloma




Curettage and bone graft (if bony)

Excision of lump 

- recurrence very unusual


2.  Osteochondroma




Cortical flow evident


3.  Brown's tumour




Primary hyperparathyroidism

Secondary hyperparathyroidism





Lytic lesion

- often seen in distal phalanx


4.  Nora's lesion


Bizarre parosteal osteochondroma


5.  Neurofibroma


Not possible to dissect free

- need to excise

- end to end anastomoses


6.  Synovial Chondromatosis


Diffuse swelling


May have calcification


7.  Juvenile Aponeurotic Fibroma


Benign fibrous tumour 

- occurs in the hands of children and young adults

- no gender predeliction 

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


Calcification is distinguishing feature

- locally infiltrative




Requires wide local excision without sacrifice of function

- local recurrence common


Metastatic fibrosarcoma after local recurrence of JAF reported

- careful follow up required


8.  Recurring Digital Fibrous Tumor of Childhood


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

- distinguished histologically by intracytoplasmic inclusion bodies within proliferating fibroblasts


Probable viral aetiology

- usually on several digits and intradermal

- recurrence rate up to 60%


Marginal excision if function compromised


No malignant potential 

- spontaneous regression described


9.  Malignant Tumours



- very rare 

- 50% lung cancer



- most common 

- chemo and radio insensitive

- only treatment is surgery


Osteosarcoma and Ewings

- quite rare


Dermatofibrosarcoma / Epitheloid Sarcoma / Synovial Sarcoma


Sarcoma Hand0001Sarcoma Hand0001





Benign tumour of Schwann cells




May have a positive Tinel's




Eccentrically located in nerve

- fascicles are splayed over it



- Malignant degeneration rare


Part of NF syndrome

- malignant degeneration may be as high as 15%




Surgical excision using microscope

- dissect fascicles off Schwannoma




Vascular Malformation



Dull ache and heaviness

- when arm dependent




Non operative


Compression garments




Nil recurrence with complete excisions


Not always possible

- multiple debulking +/- amputation





Anomalous Innervations

1.  Richie-comeau



- ulna to median in palm

- provides motor to the thenar muscles

- ulna dominate hand

- may be due to RC anastomosis


Clinical significance

- carpal tunnel syndrome with no thenar atrophy


2.  Martin-Gruber 



- median to ulna in forearm

- provides motor function to hypothenar eminence


Clinical significance

- cubital tunnel syndrome with no hypothenar atropy

- may be due to MG anastomosis




Brachial Plexus




C5 - T1

- prefixed: C4 (more common)

- post fixed: T2


Roots (3 Branches / LSD)(Interscalene)

Trunks (1 Branch)(Posterior Triangle)

Division (Clavicle)

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


Nerve roots


Formed by ventral and dorsal nerve rootlets

- in foramen

- DRG has cell bodies of sensory nerves

- rupture proximal to DRG indicates preganglionic


Run between scalenius anterior and medius



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

- nerve to subclavius (C5/6)

- dorsal scapula nerve (C5)(rhomboids)


T1 sympathetic ganglion close to T1 nerve root

- frequently injured together




A.  Upper 

- C 5/6

- merger is Erb's point

- where SSN exits

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


B.  Middle

- C7


C.  Lower

- C8/T1



- suprascapular nerve (C5,6) from upper trunk




Trunks divide into anterior and posterior

- behind clavicle




A.  Posterior cord (5)

- all three posterior divisions

- C5 - T1

- posterior to axillary artery



- radial is terminal branch

- axillary

- upper and lower subscapular

- thoracodorsal


B.  Lateral cord (3)

- anterior divisions of upper and middle trunk

- C5/6/7

- lateral to axillary artery



- MCN lateral to artery

- lateral branch of median nerve / runs across artery

- lateral pectoral


C.  Medial cord (5)

- anterior division of lower trunk

- C8 / T1

- medial to axillary artery



- medial median

- medial pectoral

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

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




Roots / ASIA


Peripheral nerves


Supraclavicular region  C4


Regimental patch C5

- axillary nerve


Radial forearm C6



Dorsal first web space C6

- radial nerve


Thumb and thenar eminence C6

- median nerve


Middle finger C7

- median nerve


Little finger C8

- ulnar nerve


Ulnar forearm T1



Medial arm T2





Nerve roots / ASIA


C5 / deltoid / bicep

C6 / wrist extensors

C7 / tricep


T1 / interossei


Adjacent nerves


Trapezius (CN Xl)

- patient shrugs shoulders against resistance


Branches from roots


Rhomboid (C5)

- dorsal scapular nerve

- patient retracts scapula

- examiner uses hand to palpate


Serratus anterior (C567)

- long thoracic nerve


A.  Patient pushes against wall

- observe for winging

- patient protracts shoulder against resistance 


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

- raise arm for them

- get them to push arm away


Branches from the trunks


Supraspinatus (C5)

- suprascapular neve

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


Infraspinatus (C5)

- suprascapular nerve

- patient tries to externally rotate shoulder with arm by side


Branches of the posterior cord (C5-T1)


Deltoid (C5)

- axillary nerve

- patient abducts arm against resistance


Latissimus Dorsi (C7)

- thoracodorsal nerve

- patient adducts horizonal arm against resistance



- upper and lower subscapular


Radial nerve


1.  Triceps (C78)

- patient extends elbow against resistance


2.  Brachioradialis (C6)

- patient flexes the elbow with forearm pronated


3.  ECRL (C67)

- radial nerve

- extend IF against resistance


4.  ECRB (C67)


- extend MF


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

- radial and posterior interosseous nerve

- patient extends wrist


5.  Supinator (C6)

- patient supinates forearm in extension


6.  EDC (C8)


- patient extends MCPJ


7.  ECU (C67)


- extend wrist


8.  Extensor pollicis longus (C7)


- patient extends thumb IPJ against resistance


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


Pectoralis major (clavicular fibres) (C6)

- lateral pectoral nerve

- patient pushes arm forwards with arm horizontal


Biceps (C56)

- musculocutaneous nerve

- patient tries to flex elbow with forearm supinated


Lateral median nerve


1.  PT (C6)

- pronate in flexion


2.  FCR (C6)

- wrist extension


Branches of the medial cord (C8 / T1)


Pectoralis major (sternocostal fibres) (C7,8)

- medial pectoral nerve

- patient places hand on hip and pushes in


Medial branch median nerve


Flexor digitorum profundus (C8)


- patient makes fist and resists extension of index finger


Flexor pollicis longus (C8)


- patient flexes distal phalanx of thumb against resistance


Abductor pollicis brevis (TI)

- patient abducts thumb at right angles to palm against resistance


Ulna nerve


Flexor carpi ulnaris (C8)

- patient flexes wrist against resistance


Flexor digitorum profundus (C8)

- patient makes fist and resists extension of little finger


Interossei (TI)




Diagnostic Issues



- nerve root patterns of sensation and motor disturbance



- peripheral nerve root pattern / cord


Supraclavicular preganglionic

- dorsal scapular / long thoracic / suprascapular nerves injured

- Horner's

- lack of sensation supraclavicular

- no tinel's


Supraclavicular postganglionic

- + Tinels

- tender posterior triangle









- suggests C8/T1 root avulsion


Posterior triangle swelling / bruising


Wasting deltoid / biceps / Pecs


Wrist drop




Hand on head

- axillary scars






Supraspinatus/ Infraspinatus

Static winging




Palpate post triangle

- tenderness

- supraclavicular post ganglionic


Tinel's in post triangle

- supraclavicular post ganglionic




Ask patient about sensory loss


Supraclavicular C4 

- suggests preganglionic injury


Axillary nerve C5 


LCNF C6 musculocutaneous


SRN C6 (1st dorsal webspace) 


C6 median n (thumb)


C7 median n (MF)


C8 ulnar n (LF)


C8 MCNF m cord (med forearm)


T1 MCNA m cord







- function of accessory nerve important


Roots / From Behind



- shoulders back

- DSN C5


Rhomboid Testing


Serratus anterior

- push shoulder forward

- LTN C5-7


Suggest preganglionic




Suprascapular Nerve (C5)

- supraspinatous

- infraspinatous


Front / Nerve Root innervation



- C5

- axillary / posterior cord



- C5

- musculocutaneous / lateral cord


Left biceps wasting



- C7

- radial / posterior cord


Wrist extension

- C6

- radial / posterior cord


Finger flexion

- C8

- median / medial and lateral cord


Finger abduction

- T1

- ulna nerve / medial cord


Decide if fits root pattern

- Otherwise consider cord injury




Post Cord

- axillary nerve (deltoid + T minor)

- radial nerve

- subscapularis

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


Medial Cord

- medial median (FDP, FPL, AbPB)

- medial pectoral (sternal head)

- ulna nerve (interossei, LOAF)

- MCNA / MCNFA (decreased sensation medially)


Lateral Cord

- lateral median (FCR, PT)

- musculocutaneous (biceps, sensation lateral forearm)

- lateral pectoral (clavicular head)




Biceps C5

Triceps C7





Cephalad joint - Neck

Concealed - axilla





Classification Leffert "OCRO"


I Open


II Closed


A  Supraclavicular 

- Preganglionic / Avulsion of Roots

- Postganglionic / Rupture of Trunks


B Infraclavicular

- cords & branches


C.  Post anaesthetic


III Radiation / Other



Iatrogenic e.g. patient positioning



IV Obstetric


A Erb C5/6

B Klumpke C7/8 T1

C Mixed


Narakas Rule of 7's


70% MVA

70% of these MBA

70% associated injuries

70% supraclavicular

70% root avulsions 

70% C8/T1 involvement

70% persistent pain




MBA most common


Gunshot Injury

- deficit 2° nerve concussion

- usually improves

- observe for 3 /12

- explore if no improvement / large residual deficit


Position of arm

- abducted above horizontal (lower lesion)

- abducted below horizontal (upper lesion)


Associated Injuries


Axillary / subclavian artery 10-20%


Fracture humerus / clavicle / scapula / ribs


Dislocations GH / AC / SC joints


Rotator cuff tears




Supraclavicular preganglionic (nerve root patterns)

Supraclavicular postganglionic (trunks)

Infraclavicular (cords)


Can be mixed

- 2 patterns can occur in one nerve root


Supraclavicular Preganglionic / Root avulsion




Severe pain in anaesthetised arm

- starts day 1 in 50%

- constant burning + superimposed `lightning shocks`down limb


Tender & swollen in posterior triangle

- pseudomeningocoeles


Tinel's negative

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


Horner's if T1


Evidence of injury to branches from roots

- long thoracic / serratus anterior

- dorsal scapular / rhomboids





- SNAP normal (as fibres in continuity with DRG)

- abnormal sensation



- denervation dorsal neck muscles (posterior rami)


Diaphram paralysis

- high nerve root lesion / phrenic nerve


MRI Neck

- pseudomeningocoeles

- empty root sleeves




1.  Erb's Palsy


C5 & 6 +/- 7

- also lose branches from roots and trunk

- long thoracic / dorsal scapular / suprascapular



- shoulder adducted & internally rotated

- elbow extended

- forearm pronated 

- waiter's tip


Brachial Plexus Erbs


Paralysis of 

- deltoid / abductors

- SS / abductor

- IS / external rotator

- biceps / supinator and elbow flexor


Sensory loss

- lateral shoulder

- lateral forearm and hand


2.  Klumpke's palsy


C8 & T1 lesion

- paralysis intrinsics, wrist and finger flexors

- sensory changes medial hand and forearm


Klumpkes Hand 1Klumpkes Hand 2Klumpes Forearm



- ptosis (drooped)

- miosis (small)

- anhidrosis (dry)

- enophthalmos (sunken)


Supraclavicular Postganglionic (trunks)




Tinel's positive


SSN / DSN / LTN intact


No Horners




Erb's Palsy


Klumpke's Palsy

- no Horner's




Peripheral nerve patterns


A.  Lateral cord weak (C5,6,7)



- biceps (C5)


Lateral cord median

- FCR (C6)

- PT (C6)


Lateral pectoral nerve

- clavicular head


B.  Posterior cord weak (C5-T1)


AXN (C5)

- deltoid


Radial nerve

- triceps (C7)

- ECRL / ECRB (C8)

- EDC (C8)

- EPL (C8)


Upper and lower SCN (C5,6)

- SSC, T major


LTN (C5,6,7)

- latissimus dorsi


C. Medial cord weak


Ulna nerve (C7,8 T1)

- FCU (C8)

- LF FDP (C8)

- interossei (T1)


Medial median Nnerve



- Thenar / APb


Medial pectoral

- sternocostal P. major





- elevated diaphragm (phrenic nerve injury)

- fractured 1st rib

- suggests root avulsion


C spine Xray

- avulsion of C7 TP 

- suggests root avulsion


Shoulder Xray

- fracture clavicle / Scapula / GHJ / ACJ / SC




Takes 3 weeks for Wallerian degeneration / denervation to occur



- muscle sample of specific groups of interest

- denervation / sharp waves & fibrillation potentials

- re-innervation / polyphasic AP on volitional activity


Preganglionic lesion



- Skin Anaesthetic 

- SNAP persist because of DRG


EMG Denervation in

- paravertebral muscles

- serratus anterior

- rhomboids


Postganglionic lesion



- skin anaesthetic

- no SNAP as due to wallerian degeneration




MRI C Spine


Nerve root avulsion

- displacement or oedema spinal cord

- empty foramen

- pseudomeningocoeles (takes 5 days to develop)


MRI Shoulder


Difficult to correctly image trunks and cords

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


Hems et al J Hand Surg Br 1999

- some usefulness in identifying level of injury in postganglionic




1.  Infraclavicular > Supraclavicular


2.  Upper trunk > Lower trunk


3.  Better in children and young adults







1.  Shoulder abduction and ER

2.  Elbow flexion

3.  Wrist extension

4.  Median nerve / C67 / lateral cord sensation

5.  Finger flexion




1.  Nerve repair / neurorrhaphy

2.  Neurolysis

3.  Nerve graft

4.  Nerve transfer / neurotisation

5.  Tendon / muscle transfer


Open injury / laceration


Immediate surgery

- can tag ends and return later

- primary repair / nerve graft



- can continue to improve over time

- blast injury to plexus


Surgical Approaches




Z incision

- longitudinal along posterior border SCM

- transverse along inferior clavicle

- longitudinal in deltopectoral groove


Supraclavicular approach

- posterior triangle

- SCM / omo-hyoid / clavicle / trapezius


Superficial dissection

- subcutaneous Tissue

- platysma

- elevate clavicular head of SCM


Deep dissection

- may need to divide omo-hyoid

- identify scalenius anterior and medius

- ligate external jugular vein

- suprascapular and transverse cervical arteries



- identify nerve roots / nerve stimulation

- nerve graft C5, C6, C7

- phrenic or accessory to SSN




Deltopectoral approach

- P. major tendon divided

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



- nerve stimulate medial pectoral nerve

- if working transfer to MCN

- or ICN / Oberlin


Pre ganglionic lesion / Nerve root avulsions



- spinal cord level nerve root reimplantation

- nerve transfers


Spinal Cord Level Nerve Root Reimplanation




Carlsted et al Neurosurgical Focus 2004

- reimplanation of nerve root avulsion in 9 year old boy

- C5 - T1

- regained motor function in arm and hand use


Carlsted et al J Neurosurg 2000

- nerve reimplantation in 10 patients

- surgery from 10 days to 9 months

- 3/10 recovered MRC grade 3 power

- better with higher lesions and earlier reimplantation


Shoulder Nerve Transfers


A.  Accessory nerve to SSN



- test trapezius

- surgery performed in the posterior triangle


Suzuki et al J Reconstruct Microsurg 2007

- accessory nerve to SSN in 12 patients

- average shoulder flexion 70o

- average shoulder abduction 77o


B.  Consider ICN to axillary nerve


Biceps Nerve Transfers


Connect to motor unit MCN


A.  Medial pectoral nerve to MCN



- much simpler than ICN

- often not intact

- test with nerve stimulator


B.   ICN to MCN



- problem is disparity in axon number

- T3-6 in males

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


Merrell et al J Hand Surg Am 2001

- 90% achieved MRC grade 3 power

- 70% grade 4 power


C.  Motor branch ulna nerve to MCN / Oberlin transfer



- use nerve stimulator

- isolate motor branch to FCU, preserving intrinsics


Sensation median nerve


ICN to lateral median


Hatori et al Plast Reconstr Surg 2009

- 17 patients

- none recovered 2 point discrimination

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


Post ganglionic lesion




A.  Late / 3 months

- evaluate recovery on EMG

- look for renervation potentials


B.  Immediate repair



- neurolysis

- nerve repair

- nerve grafting





- nerve functioning with nerve stimulator

- release nerve


Nerve repair 



- ruptured

- able to perform tensionless repair


Nerve graft



- non functioning on nerve stimulator

- long segment of clearly severely damaged nerve

- rupture unable to be repaired primarily


Graft Options

- sural nerve (30cm)

- saphenous




- C5 to SSN for shoulder abduction

- C5 to posterior division upper trunk (axillary)

- C6 to anterior division upper trunk for elbow flexion

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


Late salvage



- shoulder fusion

- elbow flexion / tendon transfers

- wrist fusion

- amputation


Shoulder fusion


Need functioning serratus anterior and trapezius

- for scapula control


Elbow Flexion


1.  Lat Dorsi transfer

- entire muscle mobilised on NV pedicle

- attached proximally & distally to replace biceps


2.  Triceps to Biceps transfer


3.  Steindler flexorplasty

- transfer of CFO to more proximally on anterior humerus

- need power of wrist flexors

- will often get some pronation deformity

- also need wrist extensors to prevent excessive wrist flexion


4.  Clark Pectoralis major transfer

- transfer of sternocostal P. major


5. Free Gracilis transfer

- innervated by ICN


Wrist arthrodesis


Mid humeral amputation



- flail limb

- limb is a hazard


Shouldn't be performed for pain relief




Nerve Conduction Studies / EMG

Pathological Processes


Two possible types of injury

1.  Axonal

2.  Myelin sheath


Myelin Sheath Damage




Commonly seen in compression

- i.e. CTD, ulna nerve at elbow

- area of focal demyelination


Can progress to a conduction block

- some or all axons simply stop working

- decreases the amplitudes




1.  Usually affects sensory fibres first

- affects motor fibres later


2.  Results in slowing of conduction velocity


3.  Prolonged distal latency

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


4.  Effect is focal

- slowed conduction velocity above block

- normal below

- can isolate level of entrapment


5.  If progresses to conduction block

- decreased amplitude


Axonal Damage




Due to severe damage to the axon

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




1.  Decreased amplitude - related to number of axons affected

2.  Normal latency and conduction velocity

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






Sensory nerve action potentials




Stimulate a sensory nerve and measure the action potential distally


Median nerve

- two stimulations over median nerve in forearm (S)

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


Ulna nerve

- stimulation over ulna nerve at elbow or wrist

- record over little finger





- time to reach distal electrodes


Conduction velocity

- simply measure distance between electrodes

- computer calculates velocity



- number of axons being stimulated

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


NCS Sensory




Diagnosis of carpal tunnel syndrome

- measure conduction velocity

- in upper limb is usually > 50 m/s

- compare to ulna nerve / standard charts

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

- usually use 0.3 ms as cut off


Ulna nerve compression


CPN compression


Radial nerve


Sciatic nerve






Combined motor action potential

- called this because is difficult to stimulate just one muscle

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




Stimulate a nerve and record from a muscle that it innervates




1.  Distal latency


2.  Conduction velocity

- stimulate at 2 points and measure difference between times

- 50 m/s UL

- 40 m/s LL


3.  Amplitude


NCS Motor




Same as for SNAP

- entrapments

- slowing of conduction velocity and latency with demyelination

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





Combine sensory and motor

- measuring electrodes simply in palm in median nerve distribution

- measure sensory and motor components

- see in delayed latency or conduction velocity

- very simple for CTD

- can move onto more specific SNAP and CMAP if needed






Proportional to number of functional axons

- loss of axons causes decrease in response amplitude

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


Conduction Velocity


Calculated fro

m the latency values

- reflects only the function of the fastest conducting fibres

- fortunately most compressive or traumatic disorders affect the largest fibres


Calculated by

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


Problem in CMAP

- the response is measured over the muscle

- the delay at the motor end plate must be considered

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

- and by the time taken for release of Ach

- typically ~1 mS

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


The Late Responses




Nerve root or proximal nerve lesions 

- cannot use simple NCS

- stimulate a peripheral nerve and recording over a muscle

- wait for a delayed signal

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


F Response




Supramaximal stimulus is applied to a nerve

- motor nerves are directly depolarised

- like all axons they conduct equally well in all directions


2 impulses


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



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

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

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




Does not measure sensory nerves




Brachial plexus injury

- want to know if nerve roots intact

- look in muscles relevant for each nerve root

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

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

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



- use MRI to see if nerve root avulsion


H Reflex


This is the electrical equivalent of the deep tendon reflex

A mixed peripheral nerve is sub maximally stimulated

- stimulates the large myelinated sensory nerves that convey muscle stretch

- they are the most easily depolarised of the axons

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

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

- depolarises the anterior horn cells 

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


Characterised by having a consistent latency 

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


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


Electromyography (EMG)




Needle placed in relevant muscle

- record electrical potential

- at rest and voluntary contraction


NCS Motor


NCS Waveform





- takes 3/52 to see

- amount of time for wallerian degeneration to occur

- if do earlier will get a false negative

- normal muscle electrically silent at rest



- spontaneous depolarisation in muscle

- fibrillations

- positive sharp waves



- takes 3/12 to see

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



- see large polyphasic motor unit potentials




Muscle problems

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


Shortfalls of EMG


It is only a sampling technique

- normal areas in an abnormal muscle may have normal potentials


Specific uses of NCS / EMG


Conduction blocks



- median nerve, ulna nerve

- confirm entrapment

- evaluate site of entrapment


Axonal / Nerve damage


1.  Radial nerve palsy with humeral fractures 



- is nerve in continuum or lacerated?


NCS / EMG cannot tell you that

- similar findings for Stage 4 and 5 Sunderland


Can give information regarding severity of injury

- denervation potentials at 3/52

- indicates Sunderland grade 3 or greater


Can give idea of prognosis

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

- reinnervation on EMG at 3/12


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


Can give you idea of prognosis

- i.e. SNAP intact at 3/12

- neuropraxia




Minimal axonal damage

- demyelinating / conduction block only

- no Wallerian degeneration





- some SNAP and CMAP still seen

- minimal denervation signs i.e. fibrillation

- means nerve is not too badly injured

- prognosis good

- should be just a neuropraxia


Laceration / Neurotmesis


Both conditions will lead to Wallerian degeneration

- severity dependant on number of axons injured



- no SNAP / CMAP

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

- see fibrillations in muscle in EMG due to denervation



- looking for reinnervation

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

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

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


Problems with NCS


1.  Obese patient

2.  Oedema

3.  Electrical inteference

- 50 MHz from fluorescent lights

- need to do in Faraday room

- difficult to do in ICU

4.  Must remove oils / moisturiser

5.  Sweat


Spinal Cord Monitoring


Used to assess spinal cord integrity during spinal instrumentation




Posterior tibial nerve stimulated

- scalp SEP used to monitor for surgical induced changes

- signal monitored is in the posterior column

- relatively immune to compromise of the anterior spinal artery

- motor control is located anteriorly in the descending corticospinal tracts



Nerve Entrapment

Median Nerve

Anatomy Median Nerve



- medial and lateral branches median nerve

- from medial and lateral cords respectively

- C5 - T1

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

- no branches in arm

- medial nerve crosses brachial artery to lie medial to it



- nerve medial to artery at elbow

- passes under bicipital aponeurosis then between heads of pronator teres

(sublime tubercle and CFO)

- medial nerve supplies PT, FCR, PL, FDS 



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

- occasionally passes deep to deep head of PT

- passes beneath arch of FDS

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

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


Median nerve 

- runs under arch of FDS to run on FDP

- crosses the ulna artery  

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

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




1.  Motor recurrent 

- usually arises laterally

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

- can pass through TCL


2.  Medial sensory branch

- gives two common digital nerves

- motor to first 2 lumbricals


3.  Lateral branch 

- supplies thumb and lateral index finger




Anterior Interosseous Nerve Palsy



Symptoms & signs due to compression of AIN


Sites of Compression



- Pronator Teres (most common)

- FDS arch

- Fascial bands 

- Bursa



- thrombosis in leash vessels over AIN



- aberrant belly FPL (Gantzer's)

- palmaris profundus

- aberrant FCR ulnar origin

- anomalous FDS origins




1.  Pain in proximal forearm

- vague pain

- most common symptom


2.  Motor deficiency



- PQ


3.  No sensory disturbance




Discomfort over site of compression


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

- weak pulp-to-pulp pinch possible

- Weak FPL / Index FDP / PQ



- resisted pronation with elbow flexed 90o








Rupture FPL / FDP

Median N entrapment

C8 lesion




Non operative Management


Avoid Aggravating Factors




Operative Management





- as per pronator syndrome




Schantz et al J Hand Surg Br 1992

- 20 cases of AIN compression

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

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

- recommended operative release



Carpal Tunnel Syndrome



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




Middle aged female

- F:M   2:1

- peak age 40-50 years

- often bilateral




Underlying process is decreased microvascular perfusion 

- normal press in CT is 2.5mmHg

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


Commonest cause in tenosynovitis




1. Decreased size

- bony abnormality / thickened TCL


2. Increased contents

- hypertrophic synovium / fracture callus / hematoma

- neuroma / lipoma

- abnormal muscle bellies / persistent median artery




1. Neuropathic Conditions

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


2. Inflammatory Conditions

- tenosynovitis / RA / infection / gout


3.  Altered fluid balance

- pregnancy / eclampsia / OCP

- thyroid problems / CRF / acromegaly / obesity


Patterns of Use


1.  Repetitive flexion / extension

- manual labour / typing


2.  Weight bearing with wrist extended

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


3.  Vibration




Transverse carpal ligament / TCL

- tuberosities of scaphoid and trapezium laterally

- pisiform and hook of hamate medially

- distal volar wrist crease proximal limit

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


Carpal tunnel

- FCR in separate tunnel with FPL separate and below

- median nerve radial to 4 FDS

- IF / LF below MF / RF

- 4 FDP at base

- FPL separate 


MRI Wrist Carpal TunnelMRI Wrist Carpal Tunnel 2


Motor Branch of Median nerve


Most important structure at risk / location can vary


1. Extraligamentous Recurrent / 50%

- branches distal to TCL with recurrent course to thenar muscles


2. Subligamentous / 30%

- branches beneath TCL / lies close to median nerve

- recurrent course to thenar muscles distal to TCL


3. Transligamentous/ 20%

- branches beneath TCL and pierces TCL to enter thenar muscles


4. Other

- proximal division

- branch from ulnar border of median nerve

- nerve superficial to TCL


Palmar Cutaneous Branch of Median Nerve

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

- usually 5 cm proximal to wrist

- Pierces deep fascia between FCR & PL




Often diverse 



- pain & numbness radial 3± digits

- nocturnal wakening with relief from shaking

- worse with driving





- thenar wasting



- abnormal thenar sensation suggests higher compression

- decreased sensation lateral 3 1/2 digits



- APB weakness


Augmented Phalen's 

- elbow extended & supinated

- wrist held flexed 60° 2 fingers for 30 seconds

- sensitive 80% / specific 99%



- percussion of the median nerve at wrist 

- paresthesia in distribution of median nerve indicate a positive test   

- sensitive 75% / specific 95%




EJ compression

- more proximal pain / AIN weakness


T1 lesion

- check interossei power


C6/7 lesion 

- similar sensory loss

- check wrist extension / triceps






Stimulate proximally

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

- measure latency / conduction velocity / amplitude


Conduction velocity

- compare to ulna nerve

- usually > 50 m/s

- median nerve slightly slower

- should be within 0.2 / 0.3 m/s

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



- > 3.5 ms = Abnormal

- > 1 ms between sides




90% sensitive


10% false negative rate

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

- normal study does not rule out CTS




Denervation activity (late change)

- spontaneous depolarisation

- fibrillations



- large polyphasic AP




Exclude wrist arthritis / tumour




Non-operative management






Wrist in neutral / Night splints







- must avoid intraneural injection

- can cause chronic pain and disability





- 2%

- most recover 6/52 after delivery

- very rarely require decompression



- splints



Operative Management




Failure non operative management

Permanent numbness / weakness

- indicates nerve damage which may not resolve




Open carpal tunnel release

Endoscopic carpal tunnel release



Open Carpal Tunnel Release 




1.  Increase volume carpal tunnel by 25% 


2.  Increases Guyon's canal

- may relieve compression ulna nerve / LF numbness

- Guyon's canal goes from triangular to circular




LA infiltration over site of release

- incision in line with radial side ring finger

- parallel to and ulna side of thenar crease

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

- divide palmar aponeurosis which has longitudinal fibres

- divide TCL which has transverse fibres

- ensure released proximally and distally

- inspect for ganglion etc


Endoscopic CTR



- transection of recurrent branch median nerve

- especially with abnormal anatomy and inexperienced surgeons




GA, Tourniquet


Proximal transverse incision at wrist crease

- insert spatula

- under TCL, feel it, clear soft tissue

- insert cannula

- exits in palm through distal incision

- wrist DF over bump with strap


Insert camera looking up at TCL

- must see transverse fibres in full for entire length

- clean with Q tip, or with probe if needed

- ensure nerve branches not crossing plane

- cut with hook knife under vision




Trumble et al JBJS Am 2002

- RCT of 192 patients open v endoscopic

- better grip strength in first 3 months

- less scar tenderness and earlier return to work

- no complications from endoscopic technique




Incorrect diagnosis


Incomplete decompression


Division of palmar branch


Palm dysaesthesia with is difficult to salvage

- sensitivity often precludes use of hand

- avoid by always staying ulnar to thenar crease



- confirmed by LA block



- explore and bury nerve ending


Hypersensitive Scar

- much more common if cross wrist crease


"Pillar Pain" 

- 4% at 10 months post surgery



- decreased with minimal nerve trauma & avoiding neurolysis


Division of recurrent branch 



- operative repair


Tenderness / sensitivity of median nerve



- due to superficial course post op



- if a real problem needs soft tissue to cover

- proximally can use pronator quadratus

- distally use hypothenar fat graft on vascular pedicle


Flexor tendon bowstringing or adhesions

- Bowstring tendons 2% of open CTR


Persistant numbness

- may take 12 months for all symptoms to resolve

- loss of Schwann cells resulting in persistent conduction block





- symptom free interval

- usually due to scar




Pronator Syndrome



Forearm pain caused by compression of median nerve


Sites of Compression


Pronator Teres

- commonest site

- hypertrophied / excess fascia


Ligament of Struthers

- remnant third head Coracobrachialis

- runs from supracondylar spur to medial epicondyle

- median nerve & brachial artery may be deep to it


Bicipital Aponeurosis

- lacertus Fibrosis

- from medial border of biceps to subcutaneous ulna border

- may be thickened


Arch of FDS

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

- inserts anterior oblique line on radius

- accessory muscle slips and anomalous origins of FDS




Pain in anteromedial EJ / volar aspect of distal arm 

- worse with repetitive pronation / supination eg tennis, tools


May have

- intermittent / nocturnal parasthesia

- some weakness




Tenderness at site of compression

- proximal flexors


Pain with resisted pronation elbow in flexion / PT


Other provocations test

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

- Bicipital aponeurosis - resisted supination flexed elbow 

- Arch of FDS - resisted flexion of FDS of MF





- confirm location 

- exclude CTS



- delayed conduction velocity across elbow 30%

- EMG abnormalities of PT or FCR





- seen with ligament of struthers




May help identify site of compression / ligament of struthers




Non-operative Management



Avoid aggravating activities



Operative Management




Medial incision

- divide bicipital aponeurosis

- release pronator teres

- release FDS

- +/- ligament of struthers if present





Radial Nerve

Pin Syndrome



Loss of PIN motor function with no pain

- multiple potential causes

- may be caused by compression as per radial tunnel

- may be post fracture or surgery

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




Often heralded by deep aching pain in forearm that resolves

- is followed by PIN weakness


Most commonly is incomplete lesion

- weakness of extension of index and middle or just thumb




No sensory loss


Characteristic radial deviation with wrist extension

- BR & ECRL functioning

- supplied by radial nerve




Can be helpful


EMG of appropriate muscles

- demonstrates denervation




Looking for mass lesion


Site of Compression 




Trauma - Monteggia fracture

Iatrogenic - surgery radial head / radius

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

Masses - lipoma / ganglia


Local injections

Lead poisoning - usually bilateral / motor palsy without sensory

Conversion reaction

Polyarteritis Nodosa

Muscle rupture




Locked trigger finger

Tendon rupture




Non operative


Splint / therapy

- wait 3 months for recovery





- ganglion / rheumatoid nodule / synovitis

- failure to recover post operatively




Operative release

- posterior approach

- between EDC and ECRB

- divide supinator


PIN in radial tunnel release



Radial Nerve Anatomy


- terminal branch posterior cord / C5 - T1

- runs anterior to subscapularis / teres major / lat dorsi

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

- enters posterior compartment of arm



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

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

- also gives the posterior cutaneous nerve of the arm

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

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



- passes anteriorly through intermuscular septum

- runs between BR / ECRL laterally and brachialis medially

- supplies these muscles and the elbow joint

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


Superficial branch

- runs under BR until it emerges between it and FCR

- runs superfical to first extensor compartment

- supplies dorsum of hand



- has superficial and deep layers

- originates from the supinator crest of the ulna

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



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

- passes under a fibrous band of ECRB

- under the radial recurrent leash of vessels

- into supinator (arcade of Frohse)

- then out from under another fibrous band of supinator

- runs over APL

- dips to run on the interosseous membrane

- ending as a small nodule which supplies the wrist joint


PIN then divides

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

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





Radial Tunnel Syndrome



Dynamic structural compression syndrome of PIN

- causing pain with little or no muscular weakness

- similar presentation to lateral epicondylitis / pain more distal




Radial tunnel begins at radiohumeral joint

Extends to end of supinator muscle


Sites of compression


PIN can be compressed by FREAS in radial tunnel


Fibrous bands

- level of radio-capitellar joint


Recurrent leash of Henry 

- radial recurrent artery

- vessels to mobile wad



- nerve branches caught between ECRB and supinator


Arcade of Frohse 

- free fibrous proximal edge supinator (superficial belly)

- most common site of compression

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

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


Supinator distal edge

- occasional cause

- always decompress to here




Pain is similar to tennis elbow

- lateral elbow joint / CEO area often radiating to wrist

- deep ache or similar to muscle cramp

- often at night

- exacerbated by exercise 

- relieved by rest




Point tenderness 5cm distal to CEO 

- more proximal with Tennis Elbow

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


Provocation test

- Arcade of Frohse 

- resisted supination



- unhelpful / usually normal


Local Anaesthetic block


Best test

- inject LA in most tender spot

- usually distal to CEO

- must produce PIN palsy to confirm diagnosis

- A prior negative injection to lateral condyle for tennis elbow




Tennis Elbow

- failure of HCLA lateral epicondyle to relieve pain

- can have both tennis elbow and radial tunnel syndrome


Radiocapitellar pathology

- OA / RA / OCD / Loose body

- no pain with supination / pronation






Tends to resolve spontaneously







Avoid provocative activities






- anterior (can release all potential sites of compression)

- posterior (can only release supinator)

- brachioradialis muscle splitting


Anterior approach


Henry's approach

- start 4cm proximal to elbow joint

- identify nerve between BR & Brachialis & then follow distally

- release any proximal fibrous bands / divide recurrent vessels

- pronate / supinate and release ECRB if any compression

- fully pronate and divide all fibres of supinator


Posterolateral approach



- incision just distal to lateral condyle for 8cm

- dissection between ECRB & EDC

- identify supinator

- find PIN distally and follow proximally


Trans-brachial approach


Brachioradialis splitting

- direct approach to radial tunnel

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

- incise BR in line of incision

- identify fat covering superficial Radial Nerve

- beneath this branch is arcade of Frohse and PIN

- extend proximally and distally till released




Jebson et al J Hand Surg Am 1997

- surgical release in 31 patients

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


Lee et al J Plast Recons Aesthet Surg 2008

- 86% good results in isolated radial tunnel syndrome

- dropped to around 50% if

- other nerve compression / lateral epicondylitis / workers compensation







Wartenberg's Syndrome



Compression of superficial branch radial nerve by ECRB / BR




Parasthesia first dorsal webspace




Up to 50% of patients also Dequervain's




Non operative







Surgical release / neurolysis




Ulna Nerve

Anatomy Ulna Nerve

Nerve supply

- C7, C8, T1 

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



- direct continuation medial cord

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

- behind MCNFA



- pierces the medial intermuscular septum to run in posterior compartment

- runs anterior to the triceps



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

- running on MCL 

- covered by osbourne's ligament

- gives articular branches to the elbow


Ulna Nerve MRI Cubital Tunnel



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

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

- nerve descends on FDP, under the cover of FCU



- nerve runs with the ulna artery to the wrist

- it emerges on the lateral aspect of FCU

- nerve is ulna to artery

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

- palmar cutaneous branch which supplies sensation over the hypothenar muscles


Guyon's canal 

- superficial to TCL

- under volar carpal / pisohamate ligament

- between hook of hamate and pisiform

- nerve is ulna to the artery

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


Motor branch 

- runs between abductor and flexor digiti minimi 

- through opponens 

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

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





Cubital Tunnel Syndrome



Symptoms & signs from compression of ulnar nerve near elbow


Sites of Compression




Arcade of Struthers 

- thick myofascial band, 1.5-2cm wide

- present in 70%

- 8cm proximal to medial epicondyle

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


Medial intermuscular septum

- with subluxation, nerve may impinge on it 


Medial head of triceps

- hypertrophied (body builders)


Medial epicondyle


Tardy ulna nerve palsy / cubitus valgus

- compression due to valgus deformity of the bone

- previous supracondylar / lateral condyle fracture


Cubital tunnel / Osbourne's ligament



- walls are humeral & ulna heads of FCU

- floor is MCL

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


Nerve compression 

- occurs in flexion as Osbourne's fascia tightens

- MCL bulges out and tunnel becomes flattened ellipse




Nerve passes intramuscular for ~5cm

- penetrates fascial layer to lie on FDP

- proximal and distal compression possible




A. Lesions in the groove

- medial epicondyle fracture / arthritic spurs / HO

- lipomas / ganglia / osteochondromas / synovitis / rheumatoid nodule

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


B. Conditions outside the groove

- external compression

- anomalous anconeus muscle


C. Subluxation / Dislocation from the groove

- laxity / traumatic tear of fibro-aponurotic roof




Pain on ulnar side of elbow

Pain & numbness in ulnar fingers

Provoked by elbow flexion

Weakness of fine movements





- deformity or carrying angle

- full ROM

- wasting intrinsics dorsum hand


Wasting Adductor Pollicis Right Hand



- tenderness tunnel

- Tinel's

- subluxation ulna nerve

- sensation in hand / involvement of dorsal and palmar branches




A.  Power FCU / FDP LF


B.  Hand

- intrinsics

- abductor digiti minimi

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


Froment's sign



- C spine

- axilla





- symptoms worse with overhead position


C spine

- neck / shoulder pain


T1 nerve root lesion

- thenar muscle power will be reduced

- decreased sensation medial forearm


C8 nerve root lesion

- IF / MF FDP & FPL weakened


Ulna tunnel syndrome

- sensation normal palmar / dorsal branch

- FCU / FDP LF normal


Pancoast tumour


Systemic illness

- DM

- alcohol

- hypothyroid

- vitamin deficiency




High false negative


Test with elbow flexed

- < 50 m/s conduction velocity across elbow




Denervation in hypothenar muscles in severe cases




Non-operative Management




50% resolve with night elbow extension splint

Avoid leaning on elbows


Rest / activity modification


Operative Management




Intrinsic weakness

Failed non-operative > 3/12




1.  Open release

2.  Endoscopic release

3.  Open release + Nerve transposition

4.  Open release + Medial Epicondylectomy


1.  Open release



- mild disease

- normal anatomy

- no subluxation





- 10cm curved incision centred over cubital tunnel

- 1/2 way between olecranon & medial epicondyle

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



- Posterior branch of MCNFA


Superficial dissection

- deepened through deep fascia

- nerve identified in proximal tunnel



- proximally ensure no arcade of Struthers

- release Osbourne ligament

- distally release fibrous band of FCU

- ensure ulna nerve stable at end of case

- if unstable, transpose



- protect distal muscular branches

- 2 branches to FCU 

- branch to FDP


Ulna Nerve ReleaseUlna nerve release test stability




Ziowodzki et al JBJS Am 2007

- meta-analysis of decompression v anterior transposition

- no deformity or previous surgyer

- no evidence of improved outcome with anterior transposition


Vogel et al Br J Plastic Surg 2004

- revision surgery in 22 patients

- combination of simple release and subcutaneous transposition initially

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

- all had submuscular transposition and Z lengthening of CFO

- 78% satisfaction rate


2.  Endoscopic Release



- normal anatomy / simple release

- no SOL / ganglion requiring removal




Small incision over epicondylar groove

- release osbourne's ligament under vision

- lift skin flaps with special retractor proximally and distally

- insert 30scope

- release remainder ulna nerve under endoscopic vision




Watts et al J Hand Surg 2009

- compared results from open and endoscopic release

- greater patient satisfaction in endoscopic with fewer complications


3. Nerve Transposition



- subluxation

- valgus deformity / FFD

- failed decompression / revision surgery



- allows functional lengthening of nerve 3-4cm

- low recurrence rate



- scar formation with possible new proximal site of compression


3 options


A.  Submuscular

- muscles elevated from CFO protecting MCL 

- nerve transposed anteriorly

- muscles reattached


B.  Intra-muscular

- 5 mm trough made in CFO 

- nerve transposed into groove

- superficial fascia closed over nerve


C.  Subcutaneous

- nerve transposed anterior medial epicondyle

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


4. Medial Epicondylectomy



- valgus deformity

- malunited fracture

- bony abnormality



- produces scarring

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

- weakens flexors (contraindicated in athlete)

- MCL injury can occur



- nerve identified, released & protected

- CFO elevated

- medial condyle & supracondylar ridge removed

- guide is medial border of trochlea

- flexor origin attached to periosteum

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




Hypertrophic scar

Neuroma MCNF


Non resolution of parasthesia

Ulna Tunnel Syndrome



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


May be purely sensory, purely motor or combination


Anatomy Guyon's Canal


4cm long ulnar tunnel


Floor - transverse carpal ligament


Roof - volar carpal ligament and pisohamate ligament


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




Ulna nerve and artery

- nerve ulnar to artery


Within canal at distal margin ulna nerve divides into 2

- superficial sensory

- deep motor branch

- separated by common tendinous origin of hypothenar muscles


3 zones


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

2.  Medial & distal to bifurcation - motor branch

3.  Lateral & distal to bifurcation - sensory branch






Soft tissue masses (including ganglia) 46%

Anomalous Muscles 16%




Repeated blunt trauma 


Can also get

- thrombosis of ulnar artery / hypothenar hammer syndrome

- fracture of hamate (Golfer)

- aneurysm ulnar artery




Pain & paraesthesia in ulnar hand & fingers


Weakness hand

- difficulty fine motor skills





- hypothenar wasting / intrinsic wasting / ulna claw hand



- decreased sensation in LF

- decreased sensation hypothenar eminence / dorsal branch suggest higher lesion



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



- Tinel's over Guyon

- Allen's test 


Cervical spine




Cubital Tunnel Syndrome


Cervical root compression




Confirm Guyon's canal site of compression




Tunnel view

- hamate fracture / pisiform OA








Non-operative Management


Restrict exacerbating activities

Splint in neutral








- radial border of FCU 

- 3 cm proximal to wrist crease 

- across crease and along line of ring finger 


Superficial dissection

- ulnar nerve isolated proximal to  wrist 

- followed into Guyon's canal 


Deep dissection

- divide volar carpal ligament

- divide pisohamate ligament

- resect hook hamate or pisiform if needed 



- injury palmar branch ulna nerve





Peripheral Nerve Injury

Anatomy of the peripheral nerve 



- loose collagenous matrix

- surrounds the individual nerve fibers within the fascicle



- thin, dense connective tissue sheath that surrounds each fascicle



- a loose meshwork of collagen  and elastin fibers 

- provides a supportive and protective framework for the fascicles

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





- focal demyelination 2° ischaemia

- full recovery by 3 months



- axon disrupted



- nerve division


Seddon & Sunderland  Grading


1st Degree / Neuropraxia

- localised conduction block leading to segmental demyelination

- axons are not injured

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


2nd Degree / Axonotemesis

- axonal injury with distal segment Wallerian degeneration

- full recovery

- nerve fibres regenerate 1 mm per day

- but > 3 months, advancing Tinel's


3rd Degree / Endoneurium disrupted

- incomplete recovery due to fibrosis

- advancing Tinel's


4th Degree / Perineurium divided / Epineurium intact


Nerve is in continuity but complete block due to scar


Poor prognosis

- perineurium disrupted

- becomes filled with scar

- no recovery, no Tinel's

- no SNAP, denervation potential

- no rennervation at 3/12 (polyphasic AP)


Often needs repair 


5th Degree / Epineurium divided

- 100% divided / neurotmesis


6th Deg (added by Susan McKinnon)

- neuroma in continuity

- mixed recovery


Injury Response 


Wallerian Degeneration


Axon dies distally

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


Schwann cell proliferation and macrophage ingrowth

- clear distal stump of axoplasm & myelin

- prepares way for new axon 


Axon Regeneration


Axon sprouts enter distal endoneural tubes

- 1-2 mm/day

- survive if contact an end organ

- sprouts often enter wrong tube & wrong end organs

- some axons fail to cross repair site & form neuroma


Axon Guidance 


1. Directional Neurotropic Cues 

- target releases tropic factor


2. Survival Neurotropic Cues 

- tube supports correct axon


3. Mechanical Alignment 

- worst


4. Contact Recognition 

- path selection based on surface


Sensory Fibres


Survive years of degeneration

- sensory return order

- pinprick / moving touch / constant touch / vibration


Muscle Fibres


Myofibrils atrophy without nerve

- 50% in 2/12

- fibrotic by 12/12

- need to repair < 9/12


Neuromuscular Junction


Receptor dispersal over 12 months

- needs to be re-innervated prior to 12 months


Receptor becomes more sensitive to ACh

- spontaneous fibrillation start Day 10 

- significant EMG changes > 2/52 


Neuronal Response


Cell body dies if very proximal axon injury

- 2° ion leakage

- if neurone survives body & nucleolus enlarges

- regenerative proteins produced

- responsible for delay in nerve recovery / regeneration


Mechanism Injury


1. Open wounds


2. Compression

- pressures > 30 mmHg impair venular epineural flow

- retards axonal transport

- alteration in intraneural BV permeability

- leads to nerve function deterioration 

- relative to length of compression & absolute pressure 



- UL 200 mmHg / Max 90 min

- LL 300 mmHg/ Max 120 min


3. Traction


4.  Thermal 


5.  Irradiation Neuritis


6.  Injection


Recovery Assessment





- 3 weeks

- fibrillation potentials

- positive sharp waves 

- spontaneous AP



- polyphasic AP  


Tinel's Sign


Percuss along the nerve

- transient tingling in nerve distribution not at injury site

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

- response fades proximally secondary to progressive myelinization


Sweat Test


Sympathetic fibres very resistant to injury

- sweat preservation 

- 20+ magnification lens 




Outcome Factors 



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

- level of injury (proximal worse than distal)

- health of patient

- time delay to repair

- pure sensory nerves do better than mixed nerves



- cut or crush

- single or double level

- surgeon factors

- nil gap, no tension on repair


Contraindications to Repair


Noncompliant patient


Hopeless outcome

Insignificant nerve eg SRN -> surgery to avoid neuroma

Insufficient skills


Types of Repair


1.  Direct


Epineurium repair without tension


Primary repair

- best chance of fascicular matching / best fit

- minimal retraction & gap formation

- historically best results

- 8/0 or 9/0 nylon


Fascicular Repair


Not usually indicated except

- distal 1/3 forearm median nerve

- distal 1/3 forearm ulna nerve

- sciatic nerve in thigh




Median nerve

- release PT and FDS radial insertion

- can transpose anterior to pronator and FDS




Rujis et al Plastic Recon Surg 2005

- meta-analysis

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


2.  Nerve Grafting 



- gaps > 2.5 cm



- cable graft

- vascularised graft


Cable graft


Graft options

- Sural / MCNF / LCFN / Saphenous


Vascularised graft



- mobilise on BV pedicle



- faster recovery


3.  Neural tubes



- absorbable synthetic tubes

- epineurium sutured to each end of tube

- nerve fibrils grow into and along tubue



- tension free repair



Aberg et al J Reconst Plast Aesthet Surg 2009

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

- no difference between two groups


3. Nerve Transfer 


4. Neuroma 


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



Tendon Transfers

Median & Ulna Nerve

IssuesMedian and ulna nerve injury


Extremely difficult

- goals of rehab must be realistic

- limited number of donors

- static procedures more prominent

- fusions, tenodesis and capsulodeses must be used




1.  Thumb Opposition


EIP to APB and EPL 

- via pulley around Pisiform and FCR

- alternative is Palmaris longus or ADM


2.  Thumb Adduction 


BR / ECRB + PL graft to P1

- via base of MC III as Adductor


3.  Thumb to index tip pinch


APL slip with free graft to 1st dorsal interosseous


+/- Arthrodesis thumb MP


4.  Thumb to LF tip pinch


EDM to deep transverse lig

EDC to little must work


5.  Power Flexion of fingers 


ECRL to all 4 fingers



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



- free gracilis graft

- into FDP

- insert vascularized ulna graft to power


6.  Sensation median nerve


Superficial radial nerve translocation

Median Nerve



High Lesion

- elbow fracture or dislocation

- forearm fracture

- penetrating forearm wound


Low Lesion

- laceration at wrist

- distal radius fracture

- carpal dislocation

- entrapment in carpal tunnel


Clinical Features


1.  Low Lesion


A.  Loss Thumb function

- paralysis of APB & Opponens 

- variable FPB

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


B.  Parasthesia Radial 3 1/2 fingers and palm


2.  High Lesion


Above +


C.  Loss flexion index and middle finger

- lose FDS IF / MF / RF / LF 

- lose FDP to IF / MF


D.  Unable to flex thumb IPJ



E. FCR + PT 


3.  Anterior Interosseous Nerve Palsy


Benediction sign

- loss FDP & FPL

- index finger and thumb straight

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


Weakness of pronation

- pronator quadratus


No thenar weakness or sensory loss



- thumb: BCR to FPL

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






Open injury

- Explore & repair


Closed injury

- Reduce fracture or dislocation

- Explore if fails to improve after 3/12

- NCS / EMG first




Maintain Joint ROM / Prevent Contractures




1.  Flexion IF / MF



2.  Flexion RF / MF

- fusion DIPJ or

- buddy to RF / LF FDP


3.  Thumb IPJ flexion

- BR to FPL


4.  Thumb Opposition

- EI to APB or



4.   Sensation thumb & radial side IF 

- for pinch grip




High median nerve / Extensor indicis to APB


Harvest EIP

- incision over index MCPJ

- EIP divided with some extensor hood

- hood repaired


2nd incision over dorsum of hand 

- free EIP from EDC


Incision over dorsoulnar wrist 

- displace tendon ulnarward

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


Tunnel across palm to thumb MCPJ

- interwoven into APB & EPL tendon


Low Median Nerve / Opponensplasty with RF FDS



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

- they will overpower a weak transfer



- loop of FCU at pisiform for pulley for donor

- pass donor through loop 

- tunnel subcutaneously across palm & attach to tendon APB


Rule of 13 S's 


In a Sensible patient, I will transfer a

- Strong, Sacrificeable, Synergistic tendon with Sufficient excursion

- Straight through a Scarless, Stable bed, Subcutaneously

- across a Supple, Sensate joint

- to achieve a Single function by Securing distally



- Sensible



- Strong (will lose 1 grade of power)

- Sacrifice able

- Synergistic

- Sufficient excursion



- Straight

- Subcutaneous

- Straight pull

- Secure distally

- Single function



- Supple

- Sensate

- Scarless




Tendon transfer

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

- reinserted into a bony part or into another tendon

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



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


Tendon Graft 

- when proximal & distal ends of a tendon are transected

- interposed into another tendon pathology


Indications 3R's


1. Replacement for lost function

- nerve injury 

- neurological disease 


2. Replacement of ruptured or avulsed tendons

- RA

- EPL in wrist fracture


3. Restoration of balance to a deformed limb

- Cerebral palsty

- stroke





Radial Nerve



1. Loss of wrist extension

2. Loss of finger extension

3. Loss of thumb extension




High lesion (loss of wrist extension)

- humeral fracture (Holstein Lewis)

- compression (Saturday night palsy)


Low lesion (PIN - wrist extension intact)

- fracture / dislocation elbow

- trauma / laceration

- iatrogenic - ORIF proximal radius


Clinical Features


High lesion

- triceps weakness uncommon (lesion usually past triceps innervation)

- wrist drop (ECRL, ECRB)

- inability to extend MCPJ (EDC)

- inability to extend thumb (EPL, EPB)

- sensory defect in anatomical snuffbox


Low lesion

- triceps intact

- wrist extension ECRB / ECRL intact

- no sensory deficit

- inability to extend MCPJ (EDC)

- inability to extend thumb (EPL, EPB)




1.  Radial Splint / Lively splint

- rubber bands & outrigger

- bands replace EPL / ECRB / EDC


2.  Simple static extension splint

- passive ROM to maintain supple joints




NCS at 3/52 

- SNAP intact - neuropraxia


EMG at 3/12

- no reinnervation potentials

- poor prognosis




1.  Explore at 4/12 if no recovery


Terzis et al Plast Recon Surg 2011

- surgical repair in 35 radial nerves

- 77% good outcome


Lee J Hand Surg Am 2008

- sural nerve grafting of high radial nerve injury

- 80% good or excellent results in regards motor function


2.  Tendon transfers



- no recovery at 6 - 9/12

- usually 1 mm / day

- should see ECRL by 6 months


Tendon Transfers




1.  Wrist Extension / ECRB


Pronator Teres


2.  Digit Extension / EDC





- is the most important wrist flexor

- only ulnar deviator / may result in radial deviation


B.  FDS middle finger



- many authors favour 

- gives strong grasp 


3.  Thumb Extension / Abduction


A.  PL to EPL 

- line of pull via 1st dorsal compartment

- works well as gives some abduction


B.  FDS to RF (if no PL)

- can pass through intra-osseous membrane or tunnel subcutaneously


High Radial Nerve Transfers


Basis is use of PT for wrist extension


Jones Transfer

1.  PT to ECRL / ECRB

2.  FCU to EDC

3.  FCR to EPL (+ EPB & APL)


Problem is that both wrist flexors are transferred

- loss of FCU may lead to radial deviation


Brand Transfer

1.  PT to ECRB

2.  FCR to EDC

3.  PL to rerouted EPL



- PL absent in 20% 

- alternative FDS RF / MF

- take through interosseous membrane or tunnel subcutaneously



1.  PT to ECRL / ECRB

2.  FCR to EPB & APL

3.  FDS MF / EDC

4.  FDS RF / EPL & EIP


Technique Brand Transfer


Set up

- tourniquet

- arm table




1.  PT incision

- over insertion on midportion radius

- dissect between ECRL and ECRB

- take entire periosteal insertion off radius

- need to keep long


2.  FCR / PL incision

- distal volar incision

- take both tendons as distal as possible



- make incision in palm over A1 pulley of RF

- if need FDS to RF must take proximal to bifurcation


3.  Dorsal incision

- proximal to extensor retinaculum, expose EDC and EPL


Transfers / Tensioning


1.  PL to EPL

- tunnel PL / FDS subcutaneously under SRN to EPL

- place thumb abducted and extended

- pulve taft weave

- through tendon 4 times at 90 degrees to each other 

- 4.0 ticron stitches at each pass

- check tension


2.  FCR to EDC

- pass FCR through all 4 tendons of EDC

- may need to take through EDMB

- check tension

- fingers should be in cascade in wrist flexion

- full extension with wrist extension


3.  PT to ECRB

- PT passed through ECRB with wrist in full extension

- again check tension


Post op


0 - 4 weeks splint

- wrist and MCPJ extension

- active finger extension (DIPJ, PIPJ)


4 - 6 weeks

- active MCPJ extension


Wrist flexor to finger extensor

- teach patient to flex wrist & extend fingers

- after a while they can extend fingers without flexing fingers


Pin Palsy Transfers


Wrist extension not required



- FCR to EDC

- PL to EPL




Ulna Nerve



Low Lesion (Below Elbow)


Injury usually at wrist

- laceration at wrist

- fenetrating forearm wound


Ulna nerve laceration wrist


High lesion / Above elbow


Injury usually at elbow

- elbow fracture / dislocation

- compression (GA) 

- tardy ulna palsy


Low Lesion


1.  Claw hand deformity



- hyperextension all MCPJ 

- flexion of IPJ of Ring & Little fingers


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


2.  Unopposed MCPJ extension - EDC 


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


2.  Loss of interossei 


Weak finger abduction / adduction

Positive Froment's sign

Hypothenar & Interossei wasting




3.  Numbness of ulnar  1 & 1/2 fingers


May have numbness of ulnar dorsum of hand

- depends on level of lesion

- if forearm, take out dorsal branch ulna nerve


High Lesion

Above +


A.  RF / LF FDP loss

- ulna paradox with less clawing 


B.  FCU weak

- weak wrist flexion




1.  Restore pinch / thumb stability

- thumb adduction (interposition to BR/ECRB)

- index abduction (EPB to 1st Dorsal Interossei)


2.  Correct MCPJ clawing


Management Low Ulna Palsy


1.  Thumb adduction


No donor long enough

- FDP LF tendon to BR / ECRB



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

- graft fixed to base P1 / normal insertion

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

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

- attach to donor tendon BR or ECRB


2.  Index Finger abduction


EPB to 1st dorsal interossei


3.  Clawing of MCPJ




Prevent hyperextension of MCPJ's

- Want to create FFD





- Zancolli Capsulodesis / volar plate advancement



- reconstruction lumbricals

- split MF FDS / ECLR into 4


Zancolli Capsulodesis 


Transverse palmar incision

- each A1 pulley opened

- flexor tendons retracted


Volar plate raised as distally based flap & advanced proximally


Finger flexed to 20°

- volar plate sutured to new position

- mild FFD MCPJ created


Management High Ulna Palsy


1. FDP to ring and little


Buddy to middle FDP



- FDP flexes IPJ's before MCPJ's

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


2. FCU


Split FCR to FCU








ACJ Arthritis



Post-traumatic (type III clavicle fractures)



4 patterns 


1. OA with osteophytes 

-  contribute to impingement


 Acromioclavicular Arthritis


2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)


ACJ OsteolysisACj Osteolysis


3. RA


4. Hyperparathyroidism




Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm




ACJ OA Clinical Photo


Tenderness to direct palpation is most reliable sign

- may feel osteophytes

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


Cross body adduction of arm 

- tends to overlap with impingement




LA + Cortisone

- inject into joint

- diagnostic / therapeutic





- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis



- Cervical root C4/5

- shoulder tip pain from abdominal pathology




Zanca view

- AP 10° cephalic tilt with 50% penetration 


ACJ OA Inferior Clavicle Osteophyte


Bone Scan


Not usually necessary


ACJ OA Hot Bone Scan






Most patients respond well


Activity modification

Steroid injection




Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment




Resect sufficient distal clavicle to prevent abutment




1.  Open excision distal clavicle

2.  Arthroscopic resection


Open Excision of distal clavicle


Post Open ACJ Excision



- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact


90% success rate


Arthroscopic ACJ Resection



- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation




Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

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

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection




1.  Identify distal clavivle

- remove bursa and perform SAD

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

- clean and identify clavicle anterior and posterior




2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

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

- must not leave posterior edge


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


Post Arthroscopic ACJ resectionSuperior AC Ligament post arthroscopic resection




ACJ Dislocation

Type 3 ACJ Dislocation



Synovial joint with hyaline cartilage


Has fibrocartilage intra-articular disc

- complete or incomplete

- usually degeneration by 4th decade


Clavicle may lie superior to acromion in normal population


Acromioclavicular Ligaments


ACJ capsule

- strongest superiorly

- horizontal / AP stability


Coracoclavicular Ligaments / CCL


Primary restraint to superior translation

- primary suspensory ligament of upper limb


Trapezoid Ligament (anterolateral)

- anterolateral on coracoid

- inserts trapezoid ridge also anterolateral to conoid

- almost horizontal in sagittal plane

- primary restraint to axial compression


Conoid Ligament (posteromedial)

- arises postero-medial to trapezoid

- inverted cone

- inserts conoid tubercle

- apex of posterior clavicular curve

- junction lateral & medial 2/3

- lies vertically

- primary restraint to superior and anterior translation


Delto-trapezial fascia

- dynamic stabiliser


Motion at ACJ


Only small 5-8o

- 40o at SC joint

- motion is at scapulo-thoracic joint rather than ACJ




Usually direct force onto adducted shoulder joint

- clavicle remains in normal position

- arm falls down




Usually clinically obvious


Grade 3 ACJGrade 3 ACJ


Allman grades I-III 1967 / Rockwood modified 1989 Classification


I     ACJ sprain


II    ACJ Disrupted & CCL intact / sprained


ACJ Dislocation Grade 2


III  Rupture ACJ & CCL 

- displaced > 100% of clavicular width


Grade 3 ACJ Dislocation


IV   Into trapezius

- can be easily missed

- need axillary lateral


Type IV ACJ APType IV ACJ Axillary LateralType IV ACJ


V     High dislocation > 1 x clavicle width

- disrupted trapezius & deltoid

- end of clavicle subcutaneous


ACJ Dislocation Type 5


VI    Subcoracoid dislocation




Zanca view

- specific for ACJ

- 10ocephalad, 50% voltage


Stress views

- occasionally used

- hold weights in each arm

- bilateral xray



- 50% overriding clavicle

- 2% under riding

- 29% incongruent

- joint width 0.5-7 mm




Type I


Symptoms 7-10 days


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

- 2/52


Type II


Sling 2/52

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

- OT if Persistent pain


Chronic Symptomatic I & II

- trapped capsular ligament / loose articular cartilage / detached meniscus

- excision outer end clavicle if continued symptoma


Acute Type III


RCT Operative vs Non-Operative


Tamaoki et al Cochrane Database 2010

- meta-analysis of 3 RCT

- operative v non operative

- multiple fixation techniques

- no obvious advantage in operative group

- RCT insufficient to decide merit of operative management


Surgical Indications



- heavy labourer

- < 25 years undecided on career

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




1.  Hook plate

- reduction of ACJ

- hook under posterior acromion

- allows CC ligaments to heal

- must be removed

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


Clavicle Hook Plate


Gstettner et al J Should Elbow Surg 2008 

- acute injuries

- hook plate or non operatively, patient choice

- 57 v 30

- hook plate removed after 3 months

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

- 3 superficial infections

- slightly improved constant scores in surgical group

- similar ROM

- improved pain and power scores



- acromial cut out

- clavicle fracture


Clavicle Hook Plate Fracture


2.  Reconstruction


Chronic Symptomatic Grade III


Excision distal clavicle


Poor results

- convert long high riding clavicle to short high riding clavicle


Reconstruction Options

- Phemister technique

- Weaver Dunn

- CCL augmentation (anchors / tightrope)

- CCL Reconstruction

- combinations


1.  Phemister technique



- open reduction of ACJ

- 2 x K wires across ACJ

- suture repair AC and CC ligaments


Calvo J Should Elbow Surg 2006

- Phemister v Non operative

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

- less radiographic OA in non surgically treated cases

- may be that K wires further damage joint

- similar functional results in each

- recommend non operative treatment


2.  Weaver Dunn Reconstruction



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

- CA ligament left attached to coracoid

- excise 1.5 (2.5cm original recommendation) lateral clavicle

- CAL taken off anterior acromion with bone fragment

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


Supplement with

- hook plate

- Bosworth Screw

- anchor / sutures

- Lars Ligament / Hamstring / allograft


3.  CCL Augmentation



- 5 mm anchor with sutures about clavicle

- tightrope constructs

- Bosworth screw


Weaver Dunn with Twinfix AnchorACJ Reconstruction TightropeACJ Reconstruction Tightrope


4.  CCL Reconstruction



- pass allograft / autograft / LARS around coracoid

- pass around clavicle and suture or

- can pass through drill holes and secure with screws

- second technique risks clavicle fracture




Tauber et al J Should Elbow Surg 2007

- 12 revision cases of failed Weaver Dunn

- autogenous ST in figure 8 configuration

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

- augmented with Bosworth / TBW removed at 3/12

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

- good results, one clavicle fracture from wire



- intra-operative fracture coracoid

- failure repair (10 - 20%)

- recurrent deformity common in surgical groups

- clavicle fracture (due to sutures or metal work)


- continued pain

- posterior dislocation (due to non intact AC ligament)

- NV damage


Type IV, V, VI


Most recommend surgery

- hook plate / reconstruction acutely

- reconstruction late


Technique Weaver Dunn + Augmentation / Reconstruction



- 45o beach chair

- sabre incision over ACJ

- split fascia transversely along the clavicle and onto acromion

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

- expose anterior aspect of acromion

- resect 1 cm of distal clavicle with microsagittal saw

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

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

- expose the coracoid laterally and carefully medially

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

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


Reduction / Reconstruction

- reduce clavicle down with preferred technique

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

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

- place drill holes through distal clavicle

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

- secure with intra-osseous sutures


Post op

- sling for 6/52

- no contact sports for 6/12


Post Weaver Dunn with Lars Ligament

Os Acromiale



Failure of fusion of adjacent ossification centers




Incidence 3%


Bilateral in 60%




4 ossification centers present in acromion

- pre-acromion

- mesoacromion

- metaacromion

- basiacromion


The basiacromion fuse to spine of scapula by 12


Pre / Meso / Meta appear by 18

- Unite by age 22 - 25

- If un-united = Os Acromiale 




1.  Meso-Acromion

-  most common

- level with posterior aspect clavicle


 Os Acominale XrayOs Acromionale MRI AxialOs Acromionale MRI Sagittal


2.  Pre-acromial

- less common

- level with anterior border acromion


 Os Acrominale MRI T2


3.  Meta-Acomial

- rare




Best seen on axillary lateral


Factors favoring diagnosis of os acromiale over fracture 

- bilateral occurrence (Xray other side)

- rounded borders with uniform space




Useful investigation

- may show oedema if problematic


Os Acromionale MRI 1Os Acromionale MRI 2


Bone scan


Can be very important

- unlikely to be symptomatic if cold

- may be symptomatic / need addressing if hot


Symptomatic Os Acromionale


1.  Non union

- painful

- MRI / bone scan shows inflammation


2.  Dynamic impingement

- fragment moves with deltoid contraction

- decreases size of SS outlet

- impingement symptoms


Os AcromionaleOs Acromionale 3





- failure of non operative treatment




1.  Excision

- small fragment / pre-acromion

- risk defunctioning deltoid

- can perform arthroscopically and leave deltoid attachment intact

- open excision with careful reattachment


Pagnani JSES 2006

- arthroscopic excision in 11 shoulders of athletes

- all returned to sport at 14 weeks

- no loss of strength detected


Os Acromiale Arthroscopic


2.  ORIF

- large fragment / mesoacromion

- take down non union

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

- especial care with deltoid reattachment


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


Risk of nonunion


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


Peckettet al JSES 2004

- ORIF in 26 patients

- Union 25/26, 2 fractures

- 30% required removal metalwork


3.  Arthroscopic SAD

AVN Shoulder

Shoulder AVN




Much less common than hip OA

- usually presents late




Similar causes as hip (AS IT GRIPS 3C)


Alcohol / Steroid / Trauma / Idiopathic




RA / RTx


Sickle Cell 

- commonest cause worldwide

- bilateral


Caisons / Chemotherapy


Blood Supply


Gerber JBJSA 1990


1.  Anterior Circumflex Humeral Artery

- primary blood supply

- becomes arcuate artery

- runs lateral aspect bicipital groove


2.  Posterior Circumflex Humeral Artery

- collateral circulation

- supplies head when GT / LT fracture


3.  Via Rotator Cuff




Wide range of AVN after 4 part fractures

- about 1/3


Recent studies to explain this


1.   Suggest 2nd anastomotic system 

- via posteromedial branches of PCHA along inferomedial capsule

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


2.  Creeping substitution

- occurs more extensively in humeral head


3.  Rich vascular tissue surrounding humeral head


Natural History



- Difficult to predict

- Somewhat related to aetiology

- Sickle cell disease tend not to progress to arthroplasty

- Steroid induced far more likely


Less severe than femoral

- non weight bearing

- less conforming joint

- scapulothoracic motion




Superior head collapse at 90° mark 

- area of peak contact stress in abduction

- ROM Maintained until late

- Glenoid rarely affected

- Soft tissue and SSC rarely contracted


Classification / Cruess modification of Ficat-Arlet 


Stage 1

- prexray change

- only seen with MRI


Stage 2

- sclerotic changes in superior central head

- sphericity maintained


Humeral AVN Stage 2Humeral AVN Stage 2 MRI


Stage 3 

- "Crescent" Sign

- mild flattening articular surface


Shoulder AVN Stage 3


Stage 4

- significant humeral collapse with loss integrity joint surface

- loose bodies


Shoulder AVN Stage 4Shoulder AVN Stage 4


Stage 5

- degeneration extends to involve glenoid


AVN Shoulder Xray




Pain is major problem

- pain before significant loss ROM

- difficulty sleeping




Shoulder AVN MRIShoulder AVN MRI Sagittal




Remove insult

- corticosteroids, alcohol


Non Operative


Maintain current shoulder ROM / Halt Progression


A.  Prevent disuse related stiffness

- passive physio


B.  Limit overhead activities

- Joint Reaction Force greatest > 90o


C.  Bisphosphonates




Core Decompression


Decrease intraosseous pressure & increase blood flow

- moderate success mainly in stage 1 or 2




Usually works well

- glenoid not usually affected

- Soft tissue and subscapularis rarely contracted 


Smith et al J Should Elbow Surg 2008

- steroid induced AVN

- survival 92% 10 year

- 2 patients needed revision for painful glenoid arthrosis

- good option




Indicated in stage V only

- beware in young patient < 65




Arthrodesis Shoulder



Indications have narrowed

- due to success of shoulder arthroplasty


1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Stabilization after resection for neoplastic lesions




Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers (no movement possible)

Charcot arthropathy (low chance union)




Permanent solution




Loss of movement at shoulder

Difficulty with activities at head level or behind the back 

Perineal care


Loss of movement at other joints 2° prolonged immobilisation




80-95% patient satisfaction


Union rates ~ 95%




Rowe 1974 Requisites after Shoulder Arthrodesis


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

- thumb to chin

- reach axilla, mouth and belt buckle

- combination of forward flexion and elbow flexion


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

- arm should hang by side with scapula flat against thorax

- no winging




Rockwood et al JBJS Am April 2001

- Abduction 10-15°

- Flexion 10-15°

- Internal Rotation 45°



1.  Technically difficult to obtain correct position intra-operatively

2.  IR most important to later function

3.  Position in reference to trunk not scapula

4.  Avoid excessive abduction & flexion

- forces the scapula to rotate & wing at rest

- leads to fatigue & discomfort




1. Need painless, supple joints above & below

2. Rigidly stabilise congruent vascular cancellous surfaces under compression

3. Bone graft & splint as needed 




Intra-articular / glenohumeral


Extra-articular /  acromio-humeral








A.  Posterior

- detach deltoid from spine

- between IS and TM


B.  Anterior

- detach deltoid from clavicle



- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- arthrodesis between humeral head and glenoid / acromion

- temporarily fix with steinman pins GHJ and acromion-humerus

- check position / ROM / no winging

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

- humerus - acromial plate if anterior approach

- humerus - scapular spine plate if posterior approach




Early skin breakdown

Loss elbow flexion



Painful metalwork

Breakage of metalwork

Suprascapular nerve entrapment

AC joint OA




Cofield & Briggs JBJS 1979

- 71 fused shoulders

- average 9 year follow up

- 96% union rate

- 75% adequate pain relief

- 70% good functional result






Hemiarthroplasty Osteoarthritis

Shoulder Anatomical HemiarthroplastyHemiarthroplasty OAShoulder Resurfacing




Fewer complications than TSR

Simpler procedure

Indicated in younger patient




Glenoid wear after hemiarthroplasty

- potential for medial migration & progressive glenoid wear

- revision to TSR almost always alleviates symptoms


Hemiarthroplasty V TSR for OA


Sandow et al J Should Elbow Surg 1999

- study randomized after inspection of glenoid

- less pain with TSR

- high revision rate in Hemiarthroplasty for glenoid wear over time

- had to cease study as TSR results significantly superior


Lo et al JBJS Am 2005

- metanalysis

- TSR superior pain relief / active ROM / patient satisfaction


Similar in AVN and fracture


Less clear for RA

- risk of glenoid component loosening


Hemiarthroplasty + Biological Resurfacing


Elhassen et al JBJS Am 2009

- 13 patients average age 34

- glenoid resurfacing with achilles allograft

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

- all had glenoid wear with no evidence of allograft


Indications Hemiarthoplasty


1.  Normal glenoid

- AVN / trauma

- replace glenoid later if needed

- simple procedure for elderly


2.  Young patient


3.  Glenoid insufficient bone stock


Clinical Case


Patient with OA treated with Hemiarthroplasty


Shoulder Hemiarthroplasty for Osteoarthritis AP


The patient developed pain 2 years later

Infection was excluded with blood tests

CT and bone scan indicative of glenoid wear

US demonstrated intact rotator cuff


CT Shoulder Hemiarthroplasty for OsteoarthritisBone Scan Shoulder Hemiarthroplasty for Osteoarthritis


Revision to TSR

- cemented 3 peg glenoid inserted

- modular body removed to access glenoid

- shorter body used to decrease humeral head height

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


Hemiarthroplasty revised to TSR


Reverse TSR


Intraoperative glenoid fracture


Avoid by

- careful reaming and drilling osteoporotic bone



1.  Rotate metaglene

- use locking screws to stabilise glenoid

2.  PA screws

- cannulated 4.0 mm screws

- inserted percutaneously from posterior




Great deal of dead space is created

- always use a drain


Nerve injuries




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


TSR Brachial PlexusReverse TSR Plexus Stretch




Spacer for Infected Reverse TSR


Sabesan et al Clin Orthop Research 2010

- 17 patients treated with 2 stage revision

- 1 recurrence of infection

- 5 dislocations


Inferior scapula notching


Reverse TSR Notching



- metaglene not placed inferiorly enough

- humeral component impinges on scapular neck in adduction




Inferior tilt / inferior translation / overhand

- place metaglene very inferior

- use eccentric glenoidspheres / overhang inferiorly

- lateralised glenosphere



- may be cause for development of late pain


Simovitch et al JBJS Am 2007

- 77 reverse Delta III shoulders

- 44% inferior glenoid notching

- anterior and posterior notching also occurred

- related to height of implantation of glenosphere +++

- less so to the prosthesis-scapular neck angle

- inferior scapula notching related to poorer clinical outcome




Failed Glenoid Reverse TSRReverse TSR Loose Metaglene




Dislocated Reverse TSR AP


Dislocated Reverse TSRDislocated Reverse TSR Lateral


Acromial Stress Fracture


Probably due to overtightening


Reverse TSR OvertighteningReverse TSR Overtightening 2


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


Reverse TSR Acromial Fracture ORIF


Glenosphere loosening from Metaglene


Reverse TSR Loose Glenosphere from Metaglene




CORR 2011 Surgical technique anterosuperior approach



1.  Templating




Rotator Cuff Arthropathy


AP in plane of scapula

- template glenoid 

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


AP humerus

- size and fit of diaphyseal and metaphyseal humeral components





- assess glenoid bone stock / version

- normally no posterior wear in cuff arthropathy


Glenoid Pre Rev TSR Axial CT



- often superior wear


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


2.  Deltopectoral approach



- long

- need to be able to access clavicle

- make need to perform clavicular osteotomy



- take SSC and capsule off LT and humerus

- often done with osteotomy as per TSR

- identify and protect axillary nerve

- take part of CAL

- remove capsule from inferior humeral neck + any osteophytes


3.  Humeral resection using guide


Make entry point in humeral head

- hand ream to determine size of stem

- insert stem with cutting block attached

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

- 155o cut

- plane of cut laterally just below anatomical neck

- usually takes a couple of millimetres of GT


4.  Glenoid


Remove capsule and labrum

- protect axillary nerve at all times

- mobilise SSC anteriorly

- need to be able to palpate anterior glenoid

- identify axillary border of scapula

- release triceps and capsule inferiorly

- must be able to feel inferior glenoid and spine


Good exposure of glenoid is key to reverse TSR

- sandbag behind spine / allows scapula to fall posterior

- tilt bed up on side of operation

- posterior and inferior glenoid retractors


Centering Guide wire passed 

- centre of inferior circle of glenoid

- should exit scapula anteriorly about 3cm medial to glenoid

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

- ensure inferior screw will be in inferior good bone

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

- wire needs to angle slightly inferior rather than slightly superior



- symmetrically ream

- remove only cartilage, just to subchondral bone


Drill central peg hole


Insert metaglene

- press fit central peg

- usually only one size

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


Inferior screw

- drill long screw (minimum 35 mm)

- should be in good bone

- is most important screw

- will exit cortex somewhere

- insert locking screw


 Reverse TSR APReverse TSR Axillary View


Superior locking screw

- feel anterior and posterior edges of coracoid

- aim between

- again will exit cortex

- 25 - 30 mm screw


Reverse TSR Coracoid ScrewReverse TSR Axillary


Anterior and posterior non locking screws/ not in every design

- are predetermined to be divergent

- get best bite possible

- can use locking or non locking


Add glenosphere

- can wait until have done humeral component and trial

- do have option for eccentric glenosphere

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

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


5.  Ream and trial humeral component


Set rotation

- is an eccentric option

- ream over trial

- insert stem and metaphyseal component

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


Trial stability

- in full ER will open slightly

- adduct and ensure not dislocating / put hand in armpit

- shuck test - entire shoulder should move first


7.  L'Episcopo


Consider Latissmus Dorsi transfer

- if no functioning external rotators

- cannot raise hand to mouth

- severe fatty infiltration / tears in IS / Tm


Detach LD anteriorly

- pass front to back

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


LEpiscopo 1LEpiscopo 2


8.  Closure SSC / LT



- 5 ticron

- through drill holes in humerus

- pass around stem


9.  Rehab



- 6/52 passive forward flexion

- 6/52 active assist

- at 3-12 begin muscle strengthening



Rotator Cuff Arthropathy for Reverse TSR




1.  RC arthropathy / > 70 / low functional demand


2.  Revision TSR


3.  Failed Hemiarthoplasty in proximal humerus fracture




Reverse TSR Xray


In rotator cuff dysfunction

- humeral head superior causing early failure of conventional TSR


Professor Paul Grammont

- convex articular surface to glenoid

- concave surface humerus

- shifts centre of rotation medially and distally to glenoid

- improves lever arm of deltoid


Limitations of conventional TSR


1.  Inability to manage GH translation


Fully conforming surfaces

- humeral and glenoid components same radius curvature

- rim loading must occur with any translation

- rocking horse mechanism


Non conforming surfaces

- glenoid radius curvature > humeral head

- diminishes contact area

- increases local contact pressure

- risk poly failure


2.  Limitation of fixation of poly to glenoid

- subject to shear forces             


3.  Limitations of stability


Anterior instability

- defects SSC or anterior capsule / glenoid


Posterior instability

- posterior glenoid deficiency / dysplasia

- deficient posterior capsule or labrum


Superior instability

- deficient SS or CA ligament / acromion

- laxity of deltoid means it cannot function

- pseudoparalysis from antero-superior escape


4.  Deltoid dysfunction

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

- without risking loosening and failure of the glenoid component


Features of Reverse TSR  


1.  GH translation

- does not permit GH translation

- due to conforming concavity of humeral component

- full surface contact maintained during range

- nil rim loading


2.  Glenoid fixation

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

- metal glenosphere fixed by press taper

- no poly to metal fixation issue

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

- reduces the moments that challenge fixation


Reverse TSR AP BiometReverse TSR Lateral


3.  Intrinsic stability

- nature of design has increased intrinsic stability

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

- deltoid force acts to stabilise the joint

- less dependence on soft tissue and CA arch


4.  Deltoid dysfunction

- able to lower or lateralise COR

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






Cuff et al JBJS Am 2008

- 96 patients with minimum 2 years follow up

- abduction increased from 61 to 110o

- flexion 60 to 120o

- ER from 13 to 30o




Wall et al JBJS Am 2007

- 191 shoulders followed for a minimum two years

- worst results in post traumatic arthritis and revision TSR

- 15 cases of dislocation

- 8 cases of infection




Guery et al JBJS Am 2006

- calculated 10 year survival rate of 90%

- noted than Constant shoulder scores deteriorated over time

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


Revision Shoulder Arthroplasty



Rule out infection

Assess rotator cuff / bone stock preoperatively


- difficult / scarring +++

- very difficult to restore any loss of ROM

Removal of prosthesis


- may not be able to revise

Humeral component

- long stem




Rule out infection


- ultrasound or xray guided aspiration

- arthroscopy for fluid and tissue sampling



- good for cuff integrity

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


CT scan

- glenoid often deficient posteriorly 

- if ignore will either be unstable posteriorly

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


Implant Removal



- often very loose

- easy to remove


Revision TSR Loose GlenoidRevision TSR Loose Glenoid


Humeral component

- most uncemented stems only proximally coated

- flexible osteotomes


Revision TSR


Glenoid bone stock restoration


1.  Cortical ring allograft

- napkin ring type

- take from calcar of a femoral neck

- cut so is thicker posteriorly to reconstitute the glenoid

- place onto freshened glenoid surface

- use uncemented glenoid

- drill central plug, then superior and inferior screws



- bone can crack, making it unstable

- need long screws with good bite, locking screws preferable

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

- enables obtain fixation with native glenoid


2.  Bulk posterior allograft


 Revision Reverse TSR Glenoid Bulk Posterior Allograft



- use femoral head

- reconstitute posterior aspect of glenoid

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

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


Revision Humeral Component



- often need long stem

- often use cement in revision circumstance


Revision TSR Long Stem Cemented Humeral Component


Rheumatoid Shoulder

IssuesRheumatoid Shoulder


Rotator cuff

- often deficient


Bone stock

- often deficient



- often posterior version 






1.  TSR



- cuff intact

- sufficient bone stock


2. Hemiarthroplasty


Indications hemiarthroplasty

- young patient

- rotator cuff not intact, too young for reverse

- insufficient bone stock glenoid


Technique if rotator cuff deficient

- CTA head

- over size humeral head / increase valgus


Cofield et al J Should Elbow Surg 2001

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

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


3.  Reverse TSR



- ruptured cuff (30%)


Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

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

- 5 patients required bone grafting of glenoid defects





TSR Technique




- head that translates 50% in all directions

- allows 30o ER with arm at side

- stable posteriorly



- antibiotics

- consider specific Propionobacterium cover

- assess ER pre-operatively




1.  Beach-chair position

- McConnell head rest

- patient at table edge / removable edge

- shoulder must overhand table

- allows GHJ extension

- need this to insert stem

- 500 ml saline bag between shoulder blades


2. T-max table with Spyder attachment


Incision / Dissection


Extended deltopectoral approach

- coracoid to deltoid insertion 


Separate deltoid & pectoralis major

- retracting cephalic vein laterally causes less bleeding

- retracting cephalic medially prevents cephalic avulsion from subclavian vein

- place Cobell retractors under deltoid


Deep dissection

- divide clavipectoral fascia on lateral edge conjoint

- elevate conjoint, feel for MCN

- replace medial retractor blade under conjoint tendon

- ER humerus and expose SSC



- blunt dissect subdeltoid space

- right up to coracoid and clavicle


Open Approach Shoulder




1.  Musculocutaneous nerve


Branch lateral cord

- penetrates coracobrachialis 3-8 cm distal to coracoid

- beware rare cases higher

- palpate MCN under conjoined tendon

- place finger under tendon and sweep downwards to palpate


Average 3 cm

- most common cause of damage = overzealous retraction

- avoid release of conjoined tendon if possible / protects MCN


2.  Axillary nerve


Terminal branch of posterior cord

- arises inferior to coracoid

- crosses anteroinferior border of subscapularis muscle

- exits quadrangular space with posterior circumflex humeral artery



- slide finger under conjoint tendon

- run downwards over SSC muscle

- hook finger anterolaterally to feel nerve

- relatively tight cord running posteriorly

- relatively protected with adduction & ER


Tug test

- palpate anterior axillary nerve under anterior deltoid

- tug on axillary nerve over SSC

- will feel the nerve moving back and forth

- ensures is intact at end of operation


Quadrangular space

- below SSC anteriorly / T minor posteriorly

- inferior is T Major posteriorly

- between long head triceps and SNOH


Splits into 2 trunks 

1. Posterior to teres minor & posterior deltoid

- terminates as superior lateral cutaneous nerve

2. Anterior passes to middle then anterior deltoid 


Releases / Exposure


1.  Coraco-acromial ligament

- place fang retractor on coracoid

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

- take anterior triangle with diathermy

- aids exposure


2.  Pect Major insertion

- divide upper 50%

- can release more if needed, but repair at end

- allows ER of humerus


Ligate Anterior Circumflex Humeral blood vessels

- 3 sisters

- at inferior SSC tendon

- can tie off with stay sutures


Identify rotator interval


3.  Identify and release biceps

- divide biceps at insertion with scissors

- perform tenodesis later


Feel and palpate supraspinatous / infraspinatous

- ensure that are intact

- otherwise repair / change to reverse TSR


4.  Release Lat Dorsi / Teres Major if needed

- ER humerus

- subperiosteal dissection with diathermy


5.  Clavicle osteotomy

- if exposure difficult

- revision / large muscular men

- divide fascia to expose clavicle

- anterior 1/3 of clavicle

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

- complete with saw / osteotome

- repair with sutures at end of case


6.  Can release conjoint tendon if needed

- usually via coracoid osteotomy

- predrill

- secure with screw later


SSC options


A. Divide SSC tendon



- easy to do



- tendon - tendon healing less reliable

- need to protect ER post operatively

- high incidence of SSC failure / poor lift off test



- want to leave long

- so don't limit ER when repairing

- insert medial 2.0 vicryl stay sutures

- take vertically right on insertion on LT

- take entire tendon plus capsule

- will repair through drill holes at end of procedure


B.  LT Osteotomy



- bone to bone healing much more reliable



- expose inferior humeral flare

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

- release inferiorly

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

- use oscillating saw

- begin in intertubercular groove

- aim to exit deep rather than shallow

- don't want saw exiting in SSC

- if take cartilage can simply excise with nibblers

- usually small 2 cm oval piece

- place ethibond stay sutures


Humeral Osteotomy



- soft tissue off inferior neck of humerus

- ER humerus to put tissues on tension

- use osteotome to remove beard osteophytes

- may need to release lat dorsi and teres major tendon

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

- stay on bone


Deliver humeral head

- Extend & ER humerus to dislocate


Identify true anatomical neck

- aided by removal of crown osteophytes

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

- this is the osteotomy site


Cut in planned retroversion


Usually 25o of retroversion

- can match to patient's own retroversion

- i.e. osteotomy removes cartilage front and back

- can reduce retroversion if large amount of glenoid retroversion present


Varus / valgus 130° to long axis


Technique 1

- flex elbow

- use forearm as protractor

- ER forearm 25o

- cut directly posteriorly


Technique 2 (Global)

- use jig

- insert humeral reamers (long and straight)

- up to templated size

- attach jig to humeral reamer

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

- dial in required retroversion

- set height of desired cut

- pin in situ


Use oscillating saw

- insert retractors to protect glenoid / infraspinatous /supraspinatous

- surprisingly small amount of bone removed


Remove humeral osteophytes

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

- fully ER head and remove posterior neck osteotophytes




Deliver proximal humerus


Insert broach

- has fins to ensure correct rotation of prosthesis

- insert trial stem

- also have head caps

- leaving the stem in prevents fractures

- leaving cap on prevents crushing cancellous bone


Surface Replacment / No stems


May have improved outcome

- recreate anatomy including version

- stem does not dictate head placement

- very difficult to overstuff joint


Glenoid Releases


Glenoid Releases


Very important for the exposure


SSC releases


Use to be 360o release

- fatty infiltration post operatively was identified on MRI

- thought to be due to denervation anteriorly


180o release

- use stay sutures to pull SSC laterally

- posteriorly identify capsule interval

- divide capsule along posterior SSC (MGHL and IGHL)

- completely elevate from anterior glenoid

- superiorly identify CHL and divide

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

- should now be able to mobilise SSC freely


Divide inferior capsule

- palpate axillary nerve

- place retractor over AXN

- divide capsule along inferior glenoid to 6 o'clock



- biceps insertion

- labrum




- push medially

- protect with sponge

- retract with fang retractor


Release anteriorly


Release inferiorly

- often more important for reverse TSR

- use cobb to elevate inferior capsule

- divide long head of triceps if needed


Continue humeral neck release

- release around neck all the way to posterior


Glenoid Exposure


TSR Glenoid Exposure 1TSR Glenoid Exposure 2


Need a straight shot at the glenoid



- flexed

- head pushed posteriorly

- IR



- on posterior lip of glenoid

- retractor displaces head posteriorly

- Fukuda retractor / Fang


Allow for stress relaxation to occur


Danger: Glenoid Fracture


Inferior retractor to protect axillary nerve
- above inferior capsule

- bunny ears / playboy retractor


Additional Techniques

- elevate patient's bed / drops arm

- tilt patient ipsilateral side up


Assess glenoid


Often posterior erosion

- OA may be due to subtle posterior instability


Posterior erosion options are


1.  Lower anterior rim 

- recreate version

- remove anterior half with reamer

- maximum 10o



- removing bone stock which is limited

- reduce vault and increase risk of vault penetration

- increase risk of difficulty seating glenoid

- medialise glenoid component

- there are no increased poly thicknesses


2.  Decrease humeral retroversion

- resect head with arm in < 25o ER


3.  Bone graft posteriorly

- use napkin ring femoral neck allograft thicker posteriorly


4.  Custom component with post wedge build up


Insert Glenoid Component


Glenoid options


1.  Cemented all poly curved back

- most common, best results


A.   Peg v central keel

- pegs may be single or multiple


B.  Flat v curved back

- curved backs may seat better


C.  Cementing

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

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

- however, demonstrated increased pullout strength with increased cement thickness


2.  Uncemented metal back

- secured with screws

- advantage is can be same prosthesis as in reverse

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

- problem is continued issues with metal / poly interface

- also problems with overstuffing

- higher rate of revision


Centre peg crucial


Vault is a triangle

- pilot hole critical

- must not penetrate vault



- usually slightly superior in TSR to equator

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

- need to match tilt as well as version


"Glenoid Centering Point" (Matsen) 

- index finger anterior to glenoid palpates centering point in sulcus 

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

- 6-8 cm medial

- wire should exit anteriorly at this point



- glenoid is sufficient size if can take central peg



- insert guide pin

- gently ream central peg

- check intact cortex with arthroscopy probe


Vault blowout

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

- especially important for central peg

- loose pressurisation of cement


TSR Central Peg BreachTSR Glenoid Vault Breach



- insert bone graft

- pressurise only intact holes


Cement Glenoid


TSR Cemented Glenoid APTSR Cemented Glenoid Lateral


Remove labrum

- allows sizing and correct orientation of glenoid


Trial size

- place trial

- ream central peg where you want it


Insert reamer

- take off cartilage

- can eccentrically ream if needed


Insert new broach

- ream for other pegs if needed

- three or five


Keep holes dry

- insert sponge


Insert cement into peg hole

- use syringe


Insert Poly

- pressurise




Overstuffing of joint causes poor ROM


1.  Height

- head sits only 3 mm above GT

- too high places excessive stress on RC


2.  Size

- small enough to close SSC

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


3.  Offset heads

- normal head offset from neck posteriorly and medially

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

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




Should be able to

A.  Inferiorly sublux head 50% glenoid

B.  Posteriorly sublux head 50% and return to centre

C.  Able to close SSC without impingement on head

D.  Close SSC with arm in ER 30o

E.  Place hand on chest


Insert stem


A.  Cemented

- don't pressurise

- can crack stem


B.  Uncemented

- very good results


Posterior Instability


1.  Posterior capsule plication

- lamina spreader between stem and glenoid

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


2.  Place sutures in capsule posteriorly

- run ethibond anteriorly through joint

- tie to conjoint tendon


3.  Place arm in ER post operatively

- de-tensions posterior capsule

- allows capsule to scar

- i.e. gunslinger position

- also keeps humeral head forward




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

- insert sutures prior to cementing stem

- 5 x drill holes

- 4 x 5 ethibond

- place arm in 30o ER

- pass in horizontal mattress suture through SSC edge


B.  LT osteotomy

- lateral drill holes in humerus

- suture through drill holes and medial to LT into SSC

- this can tend to lateralise LT, limit ER

- various techniques to avoid this

- can pass sutures about stem


Biceps tenodesis

- suture usually



Total Shoulder Replacement

IndicationsTSR All Poly Glenoid










Paralysis of deltoid

Torn rotator cuff

Insufficient glenoid bone stock




1.  Functioning / Repairable rotator cuff

- maintain stability

- maintain centre of joint rotation

- early failure if cuff deficient


TSR plus cuff repair


2.  Intact Deltoid


3.  Resonable glenoid bone stock

- commonly posterior bone loss in OA

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

- beware glenoid hypoplasia







- 35 - 40 mm



- approximately 70% glenoids are pear shaped

- remainder elliptical

- upper width average 23 mm

- lower width average 29 mm


Shoulder CT Glenoid OvalShoulder Glenoid CT Pear Shaped



- approximately 4 - 5o superior




Healthy shoulders

- mean 2o anteversion

- large range

- 14o anteverted to 10o retroverted



- RC 8o retroversion mean

- OA 15o retroversion mean

- RA 15o degrees retroversion mean




Usually triangular




30o anteverted from coronal plane


Humeral head


Retroversion 30o







- never used

- high failure rates / peri-articular fracture


Semi Constrained

- cupped glenoid



- GE > 90%

- most common design 



- cemented v uncemented

- stems v resurfacing


TSR No StemTSR Uncemented StemTSR Cemented Stem



- metal backed

- all poly


TSR Metal Backed Glenoid





- Assess head



- Assess glenoid

- OA = Posterior bone loss

- RA = Medial bone loss  / protrusio




1.  Stem

- size


2.  Head

- neck osteotomy

- head diameter and depth


3. Glenoid size




1.  Assess bone stock

- sufficent bone in glenoid

- exclude glenoid hypoplasia


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


2.  Assess version / posterior deficiency



- can be suprisingly inaccurate


Hoenecke JBJS 2010

- 2D CT depends on angle CT gantry

- 20% error > 10o

- 3D CT best



- average is 2o anteversion

- up to 15o retroversion can be normal


Options for Management Glenoid Version


A.  Neutral inclination glenoid

- reduce retroversion of head to 25o


TSR Glenoid CT Neutral Inclination


B.  0 - 10o retroversion of glenoid



- alter with reaming / 10o change is the maximum

- otherwise can run into difficulty seating glenoid

- reduce retroversion of head further


TSR Glenoid CT Mild Retroversion


C.  20o + retroversion of glenoid / deficiency



- alter up to 100 with reaming

- reduce further the retroversion of head

- glenoid bone augments / augmented poly

- may require primary glenoid osteotomy


Glenoid Posterior Deficiency.jpgGlenoid Posterior Version and Deficiency


Assess Rotator Cuff







Neer's 3 Phase shoulder rehabilitation


Phase 1 Passive motion in forward flexion & ER

Phase 2 Active Assisted 6-8 weeks 

Phase 3 Advanced muscle strengthening 3/12




1.  Pain


Pain relief good 90%


2.  ROM


Range of motion variable

- OA with intact cuff = 120° elevation

- Post fracture or huge cuff tear = 40°


ROM gain

- OA 77o

- RA 57o

- post trauma 33o


3.  Survival


Deshmuhk et al J Shoulder Elbow Surg 2005

- 93% survivorship 10 years

- 88% 15 years

- average age 60 years

- mostly Neer II prosthesis


Sperling et al J Shoulder Elbow Surg 2004

- patients under 50 having TSR (Neer II)

- 97% 10 years, 84% 20 years




1.  Subscapularis Failure



- poor reattachment

- overstuffing anteriorly

- humeral anteversion

- denervation



- trial ER on table at end

- limit rehab to this



- decreased ROM

- pain

- instability



1.  Re-repair - limited success

2.  Pectoralis major transfer

- results poor in shoulder arthroplasty

- Jost et al JBJS Am 2003

3.  Achilles tendon bone allograft

4.  Bristow

5.  Reverse




TSR Loose glenoidGlenoid Component Loosening



- 5-40%

- clinical loosening relatively infrequent

- uncemented > cemented


Glenoid lucent lines 

- relatively common 

- ~ 30-96%

- not all are associated with pain

- not all require revision


Humeral component

- loosening rare


Instability 5%





- mal-rotation humeral component most common

- subscapularis rupture

- anterior deltoid dysfunction

- glenoid component loosening


TSR Anterior Instability LateralTSR Anterior Instability AP





- attenuation cuff or frank rupture

- dynamic muscle dysfunction



- must ensure don't leave humeral head proud

- restore shenton's line

- results in eccentric loading of glenoid component & loosening 

- "rocking horse glenoid"


Shoulder Hemiarthroplasty Rotator Cuff FailureTSR Superior Escape


Posterior (most common problem) 



- excess retroversion of glenoid or humerus

- posterior glenoid erosion

- ST imbalance


TSR Posterior DislocationRevision for Posterior Dislocation TSR Combined Anterior Posterior Approach



- may need posterior approach to reduce

- allows posterior capsular plication

- alter component version / increase anteversion

- anterior releases



- especially post fracture with shortening of humerus

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

- overstuffing of joint


Post-op rotator cuff failure



- 2%



- due to head malplacement or malposition

- respond poorly to reconstruction


TSR Failed Rotator CUff



- revise to reverse TSR


Peri-prosthetic Fracture



A:  Tip of prosthesis with proximal extension

B:  Fracture at tip only

C:  Fracture distal to tip and extends into distal metaphysis


Options Humeral Shaft Fracture


A.  Non operative Management

- prothesis stable

- acceptable aligment



- prothesis stable

- fracture distal to prosthesis

- anterolateral approach and plate


TSR Periprosthetic FractureTSR Periprosthetic Fracture


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


TSR Humeral Fracture TSR Humeral Fracture United




Kumar et al JBJS Am 2004

- 16 patients

- 6 healed after 180 days of non operative treatment

- 5 required operation after 123 days non operative treatment

- recommended all fractures can be treated non operatively

- if well aligned and prosthesis stable

- if not united by 3 months, recommend intervention


Infection 1%


TSR Infected


NV injury




Ectopic Ossification




1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

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

- mark bony landmark

- prep & free drape


Lateral Decubitus Shoulder ArthroscopyShoulder Arthroscopy Lateral DecubitusShoulder Lateral Decubitus Arthrex


2.  Beachchair


A.  Beachchair table

- pillow under thighs

- arm draped free

- access to posterior shoulder

- head secured to Mayfield head ring


B.  Spyder / Tmax

- holds head secure

- good access to posterior shoulder

- hydraulic arm holder elminates need for assistant to hold arm


Shoulder Arthroscopy TmaxShoulder Arthroscopy Spyder




Shoulder Arthroscopy Portals


Posterior Portal


Shoulder Arthroscopy Posterior Portals


Main portal for arthroscopy


A.  Soft spot

- identify posterolateral acromion

- 2 cm medial & 2 cm inferior

- through deltoid

- between infraspinatous and T minor


Make stab wound at post portal

- introduce cannula & trocar

- tip towards coracoid process

- distract shoulder joint whilst inserting

- introduce arthroscope


B.  Variation

- if mainly performing subacromial / rotator cuff

- move portal lateral and superior

- 1 cm inferior and 1 cm medial to posterolateral acromion

- aims scope over cuff tear which is usually lateral

- increases distance from cuff vertically

- can view larger area


Additional portals


Anterior Glenohumeral Portals


Arthroscopy Anterior PortalShoulder Arthroscopy Portals Anterior


Rotator Interval

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

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


Shoulder Arthroscopy Rotator IntervalRotator Interval


A.  Retrograde method

- direct scope into rotator interval

- advance until rests against anterior capsule at superior edge subscapularis

- light transilluminates skin at site of portal

- ensure lateral to coracoid

- remove scope from sheath

- insert Wissinger rod / switching stick through sheath

- make stab incision

- advance rod

- insert cannula over stick

- use portal for probe & instruments


B.  Direct / anterograde

- insert 19 gauge spinal needle

- always lateral to coracoid

- pass into rotator interval

- stab incision / switching stick / cannula


Anteroinferior portal

- just above SSC

- angle to get to anterior labrum / bankart repair

- 3 - 6 o'clock


Shoulder Scope Low Anterior Portal


Anterosuperior portal

- high in rotator interval

- in angle between humeral head and biceps

- working portal for suture exchange in stabilisation surgery

- good angle for anchor insertion for SLAP repair


Anterosuperior Glenohumeral portal


Posterior Portal



- insert switching stitch through camera cannula

- insert camera through anterior cannula

- pass cannula over switching stick



- inspect / probe / repair posterior portal


Shoulder Arthroscopy Posterior Portal


Posterolateral portal


For posterior labral tears

- inferior and lateral to posterior portal

- allows placement of the inferior anchor


Shoulder Posterior Portals 1Shoulder Posterior Portals 2


Posterior Subacromial Portal


Redirect posterior cannular with blunt trochar

- remove camers

- direct it superiorly immediately below acromion once through deltoid

- sweep trochar laterally to break adhesions


Lateral Subacromial portal


Working portal

- for subacromial decompression / ACJ resection / RC surgery

- 2 - 3 cm lateral to lateral acromion

- 1 - 2 cm posterior to anterior acromion

- usually in line midportion / posterior border of clavicle

- insert needle

- should be above cuff, below acromion

- parallel to acromion


Anterosuperiorlateral Portal / Port of Wilminton


Shoulder Scope Port WilmingtonShoulder Scope Port Wilmington 2




- passes through supraspinatous

- anterolateral border acromion

- can place more posteriorly to access posterior aspect of SLAP

- in this case will pass through infraspinatous


Superior portal Neviaser / Superomedial portal



- access posterior SLAP / decompress suprascapular nerve

- pass through RC / supraspinatous

- 1 cm medial to acromion

- 1 cm posterior to clavicle




A.  Pressure pump

- usually 40 - 50 mmHg

- can temporarily increase if required


B.  Adrenaline in bags

- 1 mg in each 3L bag


Examination of GHJ


Systematic Approach


A.  Glenoid medial / Humeral head lateral

- arthritis / chondral damage


Arthroscopy Humeral Head OAGlenoid OA Arthroscopy


B.  Biceps

- careful examination / probing of insertion

- examination of intra-articular portion for degeneration

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


Arthroscopy Normal Biceps InsertionArthroscopy Normal Biceps TendonArthroscopy Normal Biceps Tendon 2


C.  Labrum

- 360o examination

- anterior / inferior / posterior


Arthroscopy Normal Anterior LabrumShoulder Arthroscopy Inferior LabrumShoulder Arthroscopy Posterior Labrum


D.  Glenohumeral ligaments




Superior Glenohumeral Ligament



- crosses subscapularis vertically


MGHL Arthroscopy


Inferior / anterior aspect of IGHL

- attachment to labrum between 3 and 6 o'clock

- look down into inferior recess

- see attachment to inferior humerus

- exclude HAGL / exclude loose body


Arthroscopy Normal IGHL Humeral InsertionNormal IGHL Glenoid AttachmentShoulder Loose Body


E.  Rotator Cuff



- examine insertion

- ER the humerus


Arthroscopy Normal SubscapularisSubscapularis Normal Arthroscopy



- examine underside and insertion

- abduct and ER

- should be no gap between cartilage and insertion


Supraspinatous Normal ArthroscopySS normal arthroscopySupraspinatous Tendon Normal Crescent Variant



- insertion at posterior humerus next to bare area

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


Shoulder Arthroscopy Infraspinatous Insertion


Neurological Complications


Uncommon (0.1%)


1. Posterior Portal

- if placed inferiorly can damage AXN below Teres minor 


2. Anterior Portal

- damages MCN if medial to coracoid

- brachial plexus & axillary artery


Clavicle Fractures

Clavicle Fracture Displaced



Usually a direct blow 

- less commonly a fall on the outstretched hand


RTA / sporting accidents commonest causes


Can be pathological as a result of radionecrosis

- eg following radiotherapy for breast cancer.  




Fractures of the clavicle are common

- 5% of all fractures

- Up to 80% involve the middle third






First bone to ossify in 5th week of foetal life

- intramembranous ossification

- medial growth plate accounts for 80% length

- medial physis last to close at 22-25 years




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

- medial convex anteriorly 

- lateral convex posteriorly  


At the junction there is little cancellous bone

- skeletal muscle covers only part of the cortical bone

- the volume of muscle in this region is small


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




It rotates approximately 40o when the scapula is elevated

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




Fractures may be divided into three regions of the clavicle 


Medial end

- fifth of the bone

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

- rare

- <5%  


Lateral clavicle fracture

- fifth of the clavicle

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

- a point marked by the conoid tuberosity

- approximately 1/3 of all clavicle fractures 



- intermediate three-fifths between these two areas 

- most common

- 70% of clavicle fractures


Clavicle Diaphysis Fracture




Examine skin

- ensure skin not threatened by spike of bone


Examine AXN

- sensation in deltoid patch


Look for scapula winging

- may be an indication for fixation




Clavicle Midshaft Displaced



- the proximal end under the pull of SCM becomes elevated

- the shoulder tends to sag downwards and forwards

- with further displacement there is overlapping and shortening 

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


Non Operative Management


Sling for comfort

- followed by early mobilisation as the pain subsides


Figure of 8 bandage 

- these do not effectively reduce the fracture 


Complications Non Operative Management


1.  Persistent bony spike

- even after normal remodelling

- may require excision


2.  Thoracic outlet syndrome

- secondary to hypertrophic non-union of the clavicle

- also due to reduced subclavicular space in a shortened malunion

- late compression of ulna nerve, brachial plexus

- symptoms with overhead activities


2.  Non union 


Clavicle Non UnionClavicle Nonunion



Neer (6) 1960 JAMA

- 2235 closed clavicle fractures treated non-operatively

- non union in only 3 (0.1%) 

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


Rowe Clin Orthop 1968

- nonunion in 0.8% of fractures treated by closed methods

- 3.7 % in those treated by open reduction


Robinson et al JBJS Am 2004

- prospective cohort study

- overall non union rate in clavicle fractures of 6.2%

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

- factors increasing risk non-union in diaphyseal fractures

- advancing age / female gender / complete displacement / comminution


3.  Malunion


Clavicle Fracture Shortened and Displaced


Hill et al JBJS Br 1997

- studied 52 completely displaced midshaft clavicle fractures

- all treated non operatively

- 8/52 (15%) developed non union

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

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


McKee et al JBJS Am 2003

- poorer functional outcome

- fractures > 2cm shortening


Clavicle Fracture Shortened


Canadian Orthopedic Trauma Society JBJS Am 2007

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

- 1 year followup

- average time to radiographic union 28 v 16 weeks

- non unions 2/62 v 7/49

- symptomatic malunion 0/62 v 9/49

- better shoulder scores at all times

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


Operative Management


Absolute indications 


Skin compromise (open fracture or severe skin tenting)

Neurovascular injury


Clavicle Fracture Skin Tenting


Open Clavicle Fracture


Relative indications


Floating shoulder 


High risk of non union / malunion

Non union


1.  Plate fixation


Clavicle PlateClavicle Plate



- fresh fractures of the middle third 

- gross displacement and angulation of the bone 

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




Bostman et al J Trauma 1997

- plate fixation (DCP / Pelvic Recon)

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

- complication rate 23% 

- infection rate was 7.8%

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

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




Lazy beach chair

- square drape

- LA with Adrenalin


Transverse incision in Langer’s line

- can make incision inferior to clavicle

- pull it up, keeps wound away from plate

- can identify and protect supraclavicular nerves

- divide platysmus as a layer to repair later

- clean and reduce fracture

- application contoured locking plate

- need 6 cortices each side



- infection

- numbness infraclavicular (tends to reduce in size)

- non union

- hardware failure

- arterial injury

- pneumothorax


2.  IM Screw 


Clavicle IM Fixation




Boehme et al 1991 JBJS Am

- 21 patients established symptomatic non union

- intramedullary Hagie pin

- autologous bone grafting

- 20/21 union

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

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




Open approach to fracture

- 2 - 3 cm

- hand drill medially 

- pass cannulated wire laterally and out through skin

- reduce fracture, retrograde pass wire medially

- drill lateral fragment

- insert cannulated 7.3 mm screw

- needs to be between 80 and 110 mm

- check x-ray to ensure good medial fixation

- BG if non union


Post op

- limit ROM above shoulder height for a period

- decreases rotational forces and reduce risk of non union


3.  External Fixation 



- open fractures 

- severely displaced fractures with damaged skin



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

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


4.  Management Malunion


Clavicle Malunion ORIF




McKee et al JBJS Am 2003

- 15 patients mean age 37 years over 4 year period

- average shortening 2.9 cm

- complaining of pain and fatigueability

- also complaining of symptoms consistent with thoracic outlet syndrome

- many complained of cosmesis

- patients had scapula winging

- osteotomy and DCP (no bone graft required)

- 1 non union

- 8/12 patients with weakness and pain improved

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




Infection / Wound Breakdown


Clavicle plate infection


Wound breakdown

- may be a result of vicryl reaction / stitch abcess

- may be better to close fascia over plate, then just use sutures to close wound



Lateral Clavicle Fracture



Elderly population

Less common in younger population


Lateral 1/3 Neer Classification


Type I


Lateral Clavicle Fracture Undisplaced


Fracture lateral to the CC ligaments

- does not extend into the ACJ

- non displaced

- most common 4:1


Type II


Lateral Clavicle Fracture



- medial to CC ligaments

- CCL ligaments attached to lateral fragment

- medial fragment displaced superiorly

- highest rate of non union



- between conoid and trapezoid

- conoid disrupted

- trapezoid remains attached to the lateral fragment

- more stable


Type III


Involves articular surface ACJ

- ligaments intact

- may present as late degenerative change


Type IV

- skeletally immature patient

- paediatric sleeve fracture

- ligaments attached to periosteum

- displacement of proximal fragment


Non Operative Management


Robinson JBJS Am 2004

- cohort of 100 displaced Type II fractures

- 20% asymptomatic non-union

- 14% of cohort required surgery

- recommended non operative treatment in middle aged / elderly


Operative Management


Operative Indications 

- Compound / skin compromise

- displaced fracture in young people

- non union




1.  Dorsal plate / locking wrist plate


Lateral Clavicle Plate


Case 1


Lateral Clavicle ORIFLateral Clavicle ORIF 2


The lateral clavice fracture has been cleaned and reduced

- held with K wire across ACJ

- high strength suture around clavicle and coracoid

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

- advantage: no need to remove hook plate


2.  Hook Plate


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


Halder et al J Should Elbow Surg 2006

- 22 patients treated with hook plate

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

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

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

- 1 clavicular fracture at end of plate

- 1 non union, 1 delayed union

- 1 infection

- most complications in patients > 60


Hook Plate Disengage


3.  Endobutton


Robinson et al JBJS Br 2010

- 16 patients under 60 with displaced type 2

- all treated under 3 weeks

- endobutton in coracoid, clavicle reduced, endobutton clavicle

- 1 symptomatic non union


Non Union


Lateral Clavicle Non unionLateral Clavicle Nonunion ORIF


Distal clavicle nonunionDistal Clavicle Nonunion




1.  Bone graft / ORIF


2.  Excise

- open

- arthroscopic


Floating Shoulder



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




Floating Shoulder


Floating Shoulder 1Floating Shoulder 2


Glenoid Neck Fracture CTClavicle Fracture CT




High velocity injuries




Fractures usually of scapular neck


Potential Problems


Disrupts the suspensory mechanism of the shoulder

- displacement disrupts normal stability of GHJ

- changes biomechanics

- subacromial pain / impingement




Little evidence

- concern with displacement of fractures

- weakness of abduction / subacromial pain / poor shoulder function

- risk of non / malunion


Used to be recommended surgery for floating shoulder


Non operative Management



- undisplaced fractures


Edwards et al JBJS Am 2000

- 20 patients with floating shoulder treated non operatively

- 11 with displaced clavicle fractures (>10mm)

- 5 with displaced scapula fracture (>5mm)

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

- excellent functional scores


Labler J Trauma 2004

- 8 treated non operative, 9 treated operative

- 5 good results in each group

- recommend nonoperative treatment for less displaced fractures

Egol et al JBJS Am 2001

- 19 patients with clavicle fracture and displaced fracture glenoid neck

- 12 non operative, 7 operative

- good results in each group

- recommend individualized treatment


Operative Management




1.  ORIF clavicle


Minimally displaced glenoid fracture


Floating Shoulder Clavicle ORIF


2.  ORIF glenoid and clavicle


Displaced scapular neck

- > 40o angulation

- > 1cm displacement

- CT useful


Leung et al JBJS Br 1993

- 15 patients floating shoulder

- all scapular neck

- ORIF clavicle + glenoid (posterior approach)

- good functional outcome in all patients



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

- may need chest tube


Rib Fracture CT

Frozen Shoulder



Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 




2% incidence

- 40 - 60 years

- Women 2:1


Sedentary workers

- Non-dominant limb


Bilateral in 10 - 40%





- Unknown

- ? Autoimmune theory



- diabetes - 35% IDDM > 10yrs

- yhyroid disorders

- stroke

- MI

- cardiac surgery

- neurosurgery

- dupuytren's


Not Associated with

- OA

- Cuff Pathology





- post surgery i.e. RC

- trauma i.e. SNOH, stabilisation

- immobilisation



- cervical radiculopathy

- axillary node clearance

- long period immobilisation


Classification Neviaser


Each lasts 4-8 months


1.  Freezing

- painful stage

- capillary proliferation, synovial hypertrophy

- develop capsular adhesions


Shoulder Arthroscopy Frozen Shoulder


2.  Frozen

- decreasing pain, increasing stiffness

- maturation and development capsular contractures


3.  Thawing

- decreasing stiffness




Neviaser described pathology of frozen shoulder 

- contracture of capsuloligamentous structures

- inflammation followed by fibrosis


Cellular basis poorly understood

- a dense matrix of type 1 and II collagen

- laid down by fibroblasts and myofibroblasts


1° Frozen Shoulder


Initial synovitis of unknown cause results in

- intra-articular adhesions

- capsulitis

- obliteration of inferior axillary fold


Subsequent development of

- subacromial adhesions

- rotator cuff contracture


Eventually spontaneous resolution


2° Frozen Shoulder

- much less synovial inflammation

- 2° due to either intrinsic or extrinsic cause


Natural History


Traditionally thought to be benign & self-limiting


Grey 1978

- 24/25 resolved by 2 years 

- Maximum 10 years


Most have no significant symptoms or functional restriction

- But not as benign as previously thought


Reeves 1975

- 60 % have residual decreased ROM 

- usually limitation ER

- only 6% claimed functional disability


Shaffer 1992

- 50% pain or stiffness at mean 7 years

- never more than mild with little functional disability




Insidious onset /  No history of trauma





- at site of deltoid insertion

- at extremes of motion


Becomes more

- diffuse / severe / constant

- interferes with sleep


Then begins to decrease

- rest pain disappears

- pain only on movement




Develops after onset of pain

Difficulty reaching

- overhead

- behind back




Muscle atrophy


No point tenderness


Markedly decreased ROM

- abduction

- ER classically

- limited GH movement, increased ST movement


Frozen Shoulder Reduced ER


DDx Causes of reduced ER

1. Frozen shoulder

2. OA

3. Unreduced posterior dislocation


Pain on forced movement

- most sensitive indicator is pain on forced ER






Arthrogram / MRA


1. Reduced volume

- <10 ml of contrast can be injected

- normal = 20-30 ml

2. Obliterated axillary capsular recess

3. Thickened capsule





- Relieve pain

- Restore range

- Remove secondary cause


Non Operative


Reassurance as first treatment


Careful explanation of 

- nature of disease

- NHx

- reassurance




Freezing Phase

- directed towards pain relief

- simple Analgesics / NSAID

- sling / ice / TENS

- intra-articular HCLA

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


Frozen Phase

- encourage hand use to avoid RSD


Thawing Phase

- gentle ROM & strengthening 

- consider intervention if prolonged / major functional disability




Lorbach et al J Should Elbow Surg 2010

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

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


Operative Options


1.  MUA



- at least after 6/12

- in late frozen or early thawing  phases



- osteopenia

- previous fracture or surgery

- history instability



- fractures & dislocations

- cuff tears

- increased inflammation & scarring


Technique (Neviaser)

- GA or interscalene block

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


1.  Abduction first

- gentle, 2 fingers

- sensation of tearing is the axillary fold tearing


2.  Rotation second

- must avoid fracture

- IR / ER in abduction


3.  HCLA +/- hydrodistension


Post-op physio




Weber Clin Rheum 1995

- average 6 months post diagnosis

- 73% full recovery

- needed 6 weeks off work


2.  Hydrostatic Distension



- needle into GHJ under LA

- joint forcefully distended by injection

- 5 ml LA

- 1 ml steroid

- up to 40 ml Saline

- distension till capsular ruptures 

- sudden drop in resistance

- immediate post-op physio




Rydell Clin Orthop 1992

- 22 patients

- 15 months

- MUA + hydrodistention + steroids

- 91% no or slight pain at 6 weeks

- 83% normal or almost normal ROM


Jacobs J Should Elbow Surg 2009

- 53 patients randomised to either MUA or steroid hydrodistention

- 2 year follow up

- no difference in two group


Quraishi et al JBJS Br 2007

- randomised trial of MUA v hydrodistention

- improved ROM in both groups

- more patients satisfaction and better shoulder scores in hydrodistention


3.  Open Release


Ozaki et al 1989 JBJS Am 1989

- one of first papers

- open release CH ligament and RC interval

- mean of 10 months post diagnosis

- MUA as part of procedure

- 94% relief of pain and complete ROM


Segmuller et al J Should Elbow Surg 1995

- released inferior and middle GH ligaments

- 24 patients

- 88% satisfied

- 76% normal function


4.  Arthroscopic release



- +++ synovitis

- very tight shoulder to arthroscope

- capsule very thick

- very limited ROM


Arthroscopy Frozen Shoulder Synovitis




1.  Release rotator interval

- remove all tissue in between biceps and SSC


Frozen Shoulder Interval Release 1Frozen Shoulder Interval Release 2


2.  Release anterior IGHL

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

- leave labrum intact / anterior to labrum

- release inferior capsule with scissors / 6 o'clock


Frozen Shoulder MGHL ReleaseFrozen Shoulder IGHL ReleaseFrozen Shoulder Release IGHL Complete


Frozen Shoulder Inferior Release with scissors


3.  Mobilise SSC

- release adhesions on posterior and superior aspect

- some advocate release of intra-articular tendinous portion


4.  Release posterior IGHL

- place camera in anterior portal

- posterior to posterior labrum

- complete inferior release


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


5.  MUA with abduction

- remove instruments and camera

- tears inferior aspect of capsule


6.  Injection of HCLA




Ogilvie-Harris et al Clin Orthop 1995

- MUA v arthroscopic release in 40 patients

- better outcomes in arthroscopic release at 2 and 5 years

- excellent in 15/20 arthroscopic

- excellent in 7/18 MUA




Glenoid & Scapula Fractures

Glenoid Fractures


Indications for Surgery



- > 5mm step

- > 1/4 glenoid rim and displaced


Ideberg Classification Intra Articular Fracture


Type I


Fractures of the Glenoid rim

I A anterior 

I B posterior


Differentiate from small bony Bankart

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


Case 1


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


Case 2


Glenoid FractureGlenoid Fracture CTGlenoid Fracture CT 2Glenoid ORIF


Case 3


Scapular fracture intraarticular glenoid axialScapula ORIF APScapula ORIF Lateral


Case 4


Glenoid Frac APGlenoid Frac AxialGlenoid Fracture CT


Type II


Transverse fracture through glenoid fossa

- inferior triangular fragment 

- exits lateral border scapula


Glenoid FractureGlenoid ORIF


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


Glenoid Fracture 1Glenoid Fracture 2Glenoid Fracture 3


Type III


Oblique fracture through the glenoid    

- exiting through superior border of the scapula

- associated with AC fracture or ACJ dislocation

- includes the Coracoid


Type IV


Similar to II, larger superior fragment

- horizontal

- exiting thru the medial border of the blade


Glenoid FractureGlenoid Fracture 2Glenoid Fracture 3


Glenoid ORIFGlenoid ORIF 2Glenoid ORIF 3


Type V



- Va =IV+II




Type VI


Extensive comminution


Glenoid Malunion


Case 1

- untreated glenoid rim fracture

- patient with chronic instability

- treated with glenoid osteotomy


Glenoid Fracture Malunion CTGlenoid Osteotomy APGlenoid Osteotomy Lateral


Scapular Fractures


A.  Body


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

- can treat non operatively


Scapula Body FractureScapular Body Fracture CT


Scapular Blade Fracture CTScapular Blade Fracture CT 2


Indications for surgery

- > 45 degrees of angulation of body


Scapular Body /> 45 degrees


B.  Neck


Indications for surgery

- > 450 angulation

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


Case 1

- > 1 cm medial displacement

- ORIF via posterior / modified Judet approach


Scapula Neck FractureGlenoid Neck Fracture


Scapula ORIFScapula ORIF 3


Case 2


Glenoid DisplacementGlenoid Displacement CT


Glenoid ORIF 1Glenoid ORIF 2


C.  Spine


Scapula Blade Fracture CTScapula Spine Fracture



D.  Acromion


Spine scapula fracture


E.  Coracoid


Coracoid Fracture 1Coracoid Fracture 2


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


Combined Glenoid and Scapula Fractures


Case 1

- displaced glenoid fracture and neck fracture

- ORIF both through posterior / Judet approach


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



Humeral Shaft Fracture

Non operative Management




< 20o sagittal

< 30o coronal

< 3 cm of shortening


Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral




1.  Vietnam Cast / hanging cast


2.  Functional bracing / Sarmiento


Functional Humerus Brace




Union rates


Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative: 20% nonunion and 12% malunion

- operative group: 8% nonunion and 1% malunion

- no differnce in time to union in two groups



Ali et al. J Shoulder and Elbow Surgery 2015

- retrospective review of 138 patients treated nonoperatively

- 17% nonunion (24/138)

- proximal fractures highest nonunion rate



Time to union and functional outcome


Papasoulis et al. Injury 2010

- literature review of functional bracing humerus shaft fractures

- average time to union 10.7 weeks

- full shoulder ROM in 80%

- full elbow ROM in 85%



Case union


Humerus shaft 1Humerus shaft 2Humerus shaft 3Humerus shaft 4Humerus shaft 5


Case nonunion

Humerus shaft nonunionHumerus nonunion


Radial Nerve Injury




Shao et al. JBJS Br 2005

- systematic review of humerus shaft fracture

- 11.8% (532/4517) radial nerve injuries

- most common with middle, and middle/distal fractures

- 70% spontaneously recovered without intervention

- recovery rate 88% in those undergoing delayed exporation (14 weeks)

- recovery rate 88% in those undergoing immediate exploration



Holstein Lewis fracture


Holstein LewisHolstein Lewis fracture


Holstein-Lewis JBJS Am 1963

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

- all were treated operatively

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

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

- the radial nerve is closely assocated with the fracture site and the fracture spike


Korompilias et al. Injury 2013

- 25 patients with complete nerve plasy and humerus shaft fractures

- 13 fully recovered by 12 weeks

- explored 12 patients with no recovery at 16 weeks

- nerve lacerated in two patients

- intact in remainder - these fully recovered by 20 - 24 weeks





Absolute indications for exploration

- open fractures

- radial nerve palsy following closed reduction



- Holstein-Lewis fracture patterns

- patient undergoing ORIF

- no recovery at 10 - 12 weeks


Expectant management

- wait 10 - 12 weeks

- if no recovery EMG

- consider exploration +/- neurolysis +/- nerve graft at that time

- if that fails, tendon transfer for radial nerve palsy


Operative Managment of Humeral Shaft Fractures






Compound fracture

Failure to obtain / maintain acceptable reduction

Radial nerve palsy post reduction

Displaced Holstein Lewis with radial nerve palsy






Floating elbow

Segmental fracture

Proximal fracture

Pathological fracture - won't heal

Bilateral humeral fractures

Obese (very difficult to splint)

Brachial plexus injury - allows early rehab


Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral




Open ORIF with plate


Intra-medullary nail




Nail v plate


Beeres et al. Eur J Trauma Emerg Surg 2021

- IM nail v open plate

- meta-analysis of 10 RCTs (500 pts)

- SR of 18 observational studies (4900 pts)

- 17% of IMN required reoperation for shoulder impingement

- IMN had faster union and lower infection rate

- no difference nonunion rates or shoulder function scores



van der Wall et al. Eur J Trauma Emerg Surg 2021

- IM nail v MIPO
- meta-analysis of 2 RCTs (87 pts)

- SR of 5 observational studies (600 pts)

- MIPO lower risk of nonunion and reintervention

- MIPO better shoulder function




Beeres et al. Injury 2021


- meta-analysis of 2 RCTS (98 pts)

- SR of 7 observational studies (263 patients)

- MIPO lower risk of nonunion

- no difference in infection or time to union



1.  Open ORIF with plate


Humeral Plate LateralHumeral Plate Long AP




Anterolateral approach - proximal 2/3 of humerus

Posterior approach / triceps split - distal 1/3 of humerus

Posterior approach with triceps flip - Holstein lewis


A.  Anterolateral Approach Humerus for proximal / mishaft fractures


Prox humerus 1Prox humerus 2Prox humerus ORIFProximal humerus ORIF


AO foundation surgical approach



Vumedi video




- proximal fractures

- midshaft fractures


Set up

- lazy beachchair

- flat with arm on arm table

- ensure can get good images of humeral head



- deltopectoral proximally (to coracoid)

- lateral humerus distally

- distally between mobile wad and biceps



- deltopectoral groove

- identify and protect cephalic vein

- take vein laterally to minimis bleeding

- can partially release deltoid insertion if needed



- follow cephalic

- open fascia laterally

- identify plane between biceps and brachialis

- biceps swept medially

- protect musculocutaneous nerve between the two

- will emerge as lateral cutaneous nerve of the forearm distally

- identify and split brachialis in midline

- can reflect brachialis medially, but will potentially damage radial innervation of medial brachialis


Distal extension

- between brachialis and brachioradialis in distal 1/4

- find and protect radial nerve as it emerges anteriorly through lateral intermuscular septum

- may be easiest to find radial nerve most distally between brachialis and bradioradialis

- avoid lateral hohman retractors in this area


Internervous plane

- radial nerve lateral brachialis

- musculocutaneous nerve medial brachialis



- narrow large fragment 4.5 mm DCP / long Philos proximal humeral plate

- minimum 6 cortices above and below


B.  Posterior Approach / tricpes split for Distal 1/3 fractures


Humerus ORIF Posterior Approach


AO foundation surgical approach



Vumedi video




- distal 1/3 fractures

- holstein-lewis fractures



- lateral approach with arm over bolster


Sterile tourniquet if needed


Midline incision

- split deep fascia

- develop interval between long and lateral heads of triceps (easiest in muscle bellies proximally)

- identify radial nerve and profunda brachii artery in proximally in spiral groove

- split triceps tendon distally



- release lateral head of triceps from humerus

- limited by axially nerve / posterior circumflex humeral artery proximally



- reflect medial head of triceps from bone medially

- care of ulna nerve which emerges posteriorly through medial intermuscular septum


C. Posterior approach with triceps flip / triceps sparing for Holstein Lewis


AO foundation radial window distal humerus





Holstein Lewis




Patient lateral with arm over bolster


Mobilise the lateral triceps from lateral intermuscular septum

- identify the radial nerve in the groove

- follow laterally until it passes anteriorly through the lateral intermuscular septum

- elevate medial head of triceps from distal humerus

- often have to elevate the radial nerve and pass the plate under

- can use a send proximal triceps split window as needed


Triceps flip Triceps flip 2




Precontoured long posterolateral distal humerus plates


Triceps flip plate 1Triceps flip 2


Humerus distal posterolateral plate 1Distal posterolateral plate 2


2. Minimally Invasive Plate Osteosynthesis




Bridge plating

Indirect fracture reduction




Surgical neck of humerus to 10 cm of elbow joint




Anterior plating with narrow 4.5 mm LCP

Lateral plating with long proximal humerus plate


Jeong et al. BMC Musculoskeletal Disorders

- 18 patients treated with narrow LCP (anterior)

- 17 patients treated with long Philos plate (lateral)

- 2 metal failures in the Philos plate group requiring revision to LCP



Technique anterior MIPO plating


Tetsworth JAAOS 2018




- patient supine

- arm on arm table

- ensure can image proximal humerus

- keep elbow flexed to aid reduction and reduce biceps tension


Narrow LCP plate

- place on arm to select appropriate size


MIPO humerus 1MIPO humerus 3MIPO humerus 2




Proximal 4 - 5 cm

- deltopectoral approach


Distal 4 - 5 cm

- anterior approach to distal humerus

- mobilise biceps laterally

- identify and protect lateral cutaneous nerve of the forearm

- split bracialis

- keep arm supinated to protect radial nerve

- avoid deep retractors laterally to protect radial nerve


Create submuscular plane

- periosteal elevator along bone


Precontour narrow LCP plate

- subtle convex curve proximally

- subtle concave curve distally

- 10 - 15 degrees internally rotated


Pass plate

- indirect fracture reduction

- secure plate proximally to bone

- reduce fracture

- distal fixation


MIPO incisions 1MIPO incisions 2MIPO incisions 3MIPO plate insertion



3.  Antegrade Humeral Nail


Humeral Nail APHumeral Nail Lateral


Relative indications


Segmental fracture - need very long plate

Impending pathological fracture


Skin compromise




Vumedi video



Set up

- lazy beach chair

- can do flat on bed, with bump under shoulder

- need to get fluoroscopy of shoulder and distal forearm

- have fluroscopy come from opposite side

- patient relatively supine to ensure ease of AP distal locking


Anterolateral approach shoulder

- longitudinal split supraspinatus

- can split at the anterior edge of supraspinatus, and retract posteriorly

- protect rotator cuff throughout


Entry with K wire or awl

- entry point at medial aspect greater tuberosity

- theorectically protects the cuff tendon

- check centred in humerus canal using fluoroscopy on AP and lateral

- increase diameter proximally with hand reamers


Pass guide wire

- can do closed

- can perform mini open incision over fracture site

- use finger to blunt dissect and protect radial nerve


Minimal reaming


Pass nail

- typically 7 mm

- ensure that nail is buried enough to protect cuff

- need to consider hardware removal


Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon


Distal AP locking screw/s


Careful repair of rotator cuff




Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff


Humerus Prominent IM Nail


Non Union






Mean time to union is 13 weeks

No evidence of callous on xrays taken 6 - 8 weeks apart


Fracture patterns

- highest risk is transverse fractures

- proximal humerus shaft fractures also at risk due to displacing force of pectoralis and deltoid, and LHB may interpose




Peters et al. Injury 2015

- systematic review of union rate after operative intervention of humeral shaft non union

- plate only 95%

- plate and bone graft 98%

- IMN 66%

- IMN + bone graft 88%

- external fixation 98%





Vumedi video



Humerus nonunion plateHumerus nonunionHumerus nonuion plate 1Humerus nonunion plate 2



- fracture site dependant

- 4.5 mm plate with 6 cortices above and below

- if use 3.5 mm long proximal humeral plate, suggest 8 cortices below

- use iliac crest bone graft

- consider dual plating in proximal fractures with insufficient fixation, or in poor bone quality




Acute Anterior Dislocation

EpidemiologyAnterior Shoulder Dislocation


Most common form of shoulder instability

- young males 

- M:F = 2:1




Indirect ER and abduction moment on arm

- disruption of anterior stabilisers




Initial injury

- severe pain in shoulder

- ± transient paraesthesia / dead arm syndrome


History of dislocations




Very painful & tender shoulder

- significant muscle spasm

- arm held across abdomen


Hollow under acromion

- fullness in anterior shoulder


Axillary nerve palsy

- important to exclude

- look for parasthesis in badge area

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

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


Left Deltoid Wasting


Musculocutaneous Injury + Rotator Cuff Tear


Musculocutaneous nerve injuryMusculocutaneous Nerve Injury 2Supraspinatous Infraspinatous Wasting


Diagnostic Dilemma


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

1.  Wasting deltoid (AXN)

2.  Wasting SS, not IS (RC tear)

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

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


Axillary nerve palsy with Massive Rotator Cuff Tear




True AP

- dislocation

- fracture GT

- bony bankart


Shoulder Dislocation Greater Tuberosity FractureAnterior Shoulder Dislocation AP


AP in IR

- Hill Sachs lesion


Scapular Lateral

- dislocation

- humeral head should be in centre of Y


Anterior Shoulder Dislocation0002Shoulder Anterior Dislocation Scapula Lateral


Axillary Lateral

- dislocation

- Hill Sachs


Shoulder Fracture DislocationAnterior Shoulder Dislocation Axillary LateralShoulder Hill Sachs Axillary Lateral



- aim beam caudally

- bony bankart


Bony Bankart Xray




According to direction seen on xrays

1. Subcoracoid / most common

2. Subglenoid

3. Intrathoracic







- appropriate analgesia & muscle relaxation / conscious sedation

- atraumatic closed reduction performed

- if unsuccessful, may require GA

- rarely need open reduction


Post-reduction xray

- confirm reduction

- rule out associated fracture


Shoulder Post Dislocation Check ReductionBony bankart xray




1.  Stimpson

- patient prone

- arm hanging over side of bed

- weight applied to wrist

- give mild sedation

- not appropriate if obese / sleep apnea etc


Stimpson Method


2.  Harvard / Traction & Countertraction method

- patient supine

- traction with abduction

- countertraction via sheet around axilla

- similar to Hippocratic but no foot in the axilla


3.  Kocher

- externally rotate and maximally abduct arm

- relocate via adduction

- nil IR til located to avoid humeral fracture


4.  Hippocrates

- foot in arm pit

- apply longitudinal traction 




No effect on re-dislocation rate

- no sport for 6/52 reduces dislocation rate



- sling for comfort

- avoid provocation 6/52

- no sport until painless FROM


ER brace



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

- may reduce redislocation rates

- problems with compliance as is uncomfortable and in young population


Itoi et al JBJS Am 2007

- RCT ER brace v sling 198 patients 3 weeks duration

- relative risk reduction 38%

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

- particularly beneficial if < 30


Finestone et al JBJS Br 2009

- RCT 51 patients

- no difference




Start with ROM exercises

- pendulum / active Assisted / active


Progress to shoulder strengthening




1. Age at first dislocation


Increased in young

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


Classic paper Rowe CORR '61

- < 20    90% redislocation

- 20-30  60% redislocation

- 30-40   30% redislocation

- > 40     10% redislocation


McLaughlin and MacLellan 1967 

- 95% traumatic dislocations in teenagers recurred


Simonet and Cofield 1982 

- overall incidence of recurrence 33% over 4 years

- 66% in patients < 20 years

- 17% in patients 20 - 40 years


2. Trauma of First Dislocation


Decreased incidence of re-dislocation with 

- severe trauma

- associated fracture (usually LT / GT)


3. Activity


Re-dislocation more common in athletes

- 80% in athletes

- 30% in non-athletes


4. Rehabilitation


Activity restriction & effective muscle strengthening reduces re-dislocation

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

- need strict adherence with program


Indications Operative Management in Acute Dislocation


1.  Rotator cuff tear

2.  Displaced GT fracture

3.  Large glenoid rim fracture

4.  ? Athlete


Rotator cuff tear




Important not to miss

- high incidence in patients > 40

- suspect if pain or decreased ROM





Berbig et al J Should Elbow Surg 1999

- prospect ultrasound on 167 patients with dislocation

- full thickness tears in 31.7%

- only acute tears in patients younger than 60

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


Management Options


A.  Repair RC / leave Bankart

B.  Repair RC and Bankart


Voos et al Am J Sports Med 2007

- retrospective review of arthroscopic repair of RC and labrum

- average age 47, 16 patients

- good or excellent results in > 90%


2.  Displaced GT Fracture



- > 5 mm displacement




- screw + suture repair

- screw alone in young patient


Shoulder Dislocation Non Displaced GT FractureGT ORIF


3.  Large Glenoid Rim Fracture



- > 25 - 30% and displaced



- open or arthroscopic

- fix with 1 or 2 cannulated screws


Glenoid Rim FractureGlenoid Rim Fracture CTGlenoid Rim ORIF


4.  Acute dislocation in professional athlete


Robinson et al JBJS Am 2008

- prospective randomised control trial arthroscopic surgery in first time dislocators

- 88 patients under 35, arthroscopic stabilisation v arthroscopic lavage

- reduced risk of recurrence by 80%

- patient satisfaction and shoulder scores significantly improved


Kirkley et al Arthroscopy 2005

- RCT of 40 patients for arthroscopic stabilisation v immobilisation

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

- small improvement in shoulder scores in operative group


Jakobsen et al Arthroscopy 2007

- RCT 76 patients

- arthroscopy to diagnose labral injury

- either open repair or non operative

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

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

Anterior Instability



Traumatic initial cause in 95%


M:F 2:1


Age of initial dislocation inversely related to recurrence rate

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

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

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


Anatomy & Stability


1. Passive Stabilisers


Glenoid labrum 

- significant deepening by 50%

- labrum attaches capsule / ligaments / biceps


Negative intra-articular joint pressure


Joint fluid adhesion/ cohesion



- attaches to SNOH


Coracoacromial arch

- prevents superior displacement


Coracohumeral ligament

- attaches base of coracoid

- to lesser and greater tuberosity 

- passess through rotator interval between SS and SSC

- static restraint to anteroinferior translation in the adducted shoulder


Capsulo-ligamentous structures


1.  IGHL


Most important

- resists anterior translation in abduction and ER

- anterior & posterior band with sling between

- anteror band limits ER at abduction > 90°



- anterior band glenoid 3 o'clock

- posterior band 9 o'clock



- inferior anatomical neck / head


Arthroscopy Normal IGHL Humeral AttachmentIGHL


2.  MGHL


MGHL in Buford Complex



- behind SSC

- 2° restraint anterior translation

- limits ER at 45° Abduction

- present in 60% population



- supraglenoid tubercle below SGHL



- medial to LT


3.  SGHL





- adjacent to biceps tendon

- prevents inferior subluxation 

- functions only in adduction

- no function in decreasing anterior translation

- present 50% population



- supraglenoid Tubercle 



- LT


2. Dynamic Stabilisers


Rotator Cuff

- SSC resists anterior translation

- compresses head into glenoid socket


LH Biceps



- especially when arm is elevated 90o


Scapular Rotators 

- move glenoid into stable position




No essential pathological lesion responsible for every recurrent subluxation or dislocation


Thomas and Matsen Aetiology Classification



- Atraumatic, Multidirectional, Bilateral

- Rehabilitation, Inferior capsular shift, closure rotator Interval



- Traumatic, Unidirectional, Bankart, Surgery


1.  Labrum / Ligament / Capsule


A.  Bankart lesion



- described in 1938 

- humeral head forced through capsule

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

- is an IGHL avulsion

- usually between 3 and 6 o'clock



- see detachment of anterior labrum


Anterior Bankart Lesion MRIShoulder MRI Anterior Bankart




Anterior bankart lesion ArthroscopyArthroscopy Soft Tissue Bankart



- present in 85% traumatic recurrent dislocations 

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


B.  Excessive Capsular laxity 



- may be present alone or with Bankart lesion

- 30% have both

- 85% previous failed surgical procedures



- congenital collagen deficiency / MDI

- plastic deformation of capsuloligamentous complex

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


C. Capsular Tears


Capsular Tear 1Capsular Tear 2Capsular Tear 3


Capsular Repair 1Capsular Repair 2





- avulsion of IGHL from anterior humeral neck

- Humeral Avulsion of Glenohumeral Ligament



- 2 - 10%



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

- association with subscapularis tear



- may see bony avulsion



- enlarged inferior  pouch

- discontinuity of IGHL / J sign


MRI Normal Humeral IGHL InsertionMRI HAGL J Sign



- will see exposed subscapularis muscle


Arthroscopy HAGL Normal Humeral attachment IGLH




A.  Open Repair

- take down SSC

- repair via bone anchors to inferior neck

- can cause limitation ER


B.  Arthroscopic repair

- 70o scope and 5 o'clock portal


E.  Bankart Variations



- anterior labrum periosteal sleeve avulsion

- labral-ligamentous structures shifted medially

- roll up under the periosteum


Perthes Lesion

- stripping of the scapular periosteum medially

- labrum may or may not be attached


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



- glenoid labrum articular disruption

- damage to the glenoid cartilage

- labrum undisplaced


Shoulder GLAD


F.  Muscle


Cuff Tears

- Present as pain or weakness 

- > 40 years = 30%

- > 60 years > 80% 


Increased Rotator Interval

- between SS and SSC

- tends to open up with AMBRI


2.  Bony


A.  Bony Bankart



- AP

- Garth (aim beam caudally)


Bony bankart XrayShoulder Garth ViewBony Bankart



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



- may need CT to decide the size best


Burkhart and De Beer Arthroscopy 2000

- described the inverted pear appearance

- loss of bone antero-inferior




CT Sagittal Small Bony Bankart




CT Axial Large Bony BankartCT Axial Large Bony BankartLarge Bony Bankart


Size calculation


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


Lo Parten and Burkhart, Arthroscopy 2004

- calculation of percentage bone loss arthroscopically


1.  Inferior glenoid is nearly a perfect circle

- centre is the bare area of the glenoid

- measure anterior radius v posterior radius at this level


2.  Calculate the diameter of the inferior circle

- twice the posterior radius


3.  Calculate the difference between anterior and posterior radius


The average diameter is 24 mm

- hence 12 mm posterior and 12 mm anterior

- if lose 8 mm anteriorly

- 12 mm posterior and 4 mm anterior

- calculation is 8/24 = 30%




25% loss and above poor prognostically

- means approximately 7.5 mm anterior bone loss

< 4mm anterior to bare area

- > 30%

- likely not amenable to soft tissue bankart repair alone


Acute Bankart Repair


Sugaya et al JBJS Am 2005

- demonstrated union of fragment with arthroscopic restoration

- must mobilise fragment, restore anatomically

- otherwise bony procedure


Decision Making


A.  Small fragment < 15%

- arthroscopic bankart repair

- can attempt to include fragment


B.  Intermediate 15 - 25%


C.  > 25%

- must restore glenoid rim

- acute restoration of bony frament or

- bony procedure / Latarjet / Bristow


B.  Hills Sachs Lesion 



- lesion posterior aspect of head

- where head engages on anterior glenoid



- AP with IR

- Garth view


Hill Sachs XrayLarge Hill Sachs Xray




Hill Sachs CT



- cartilage each side of lesion

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


Arthroscopy Hill Sachs LesionLarge Hill Sachs



- large lesion can contribute to dislocation

- head engages defect in external rotation & abduction


Large Hill Sachs MRICT Hill SachsHill Sachs


Dynamic CT

Dynamic CT 1Dynamic CT 2Dynamic CT 3




Estimate percentage of articular surface

- concern if 25% or more


Hill SachsHill Sachs Measurement


Hill SachsHill Sachs measured


Management options for engaging Hill Sachs


1.  Posterior capsular advancement / Remplissage

2.  Humeral head allograft

3.  Anterior Bony Procedure / Latarjet / Bristow

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

4.  Humeral osteotomy





- described by Wolf Arthroscopy 2008

- advance IS into Hill Sachs lesion

- makes lesion extracapsular



- perform arthroscopic transtendinous advancement of IS and capsule into defect

- tie knots from subacromial space




Zhu et al Am J Sports Med 2011

- 8.2% failure in 42 cases


Humeral head allograft


Humeral Head Allograft APHumeral Head Allograft Lateral.jpg



- anterior deltopectoral approach

- ER shoulder

- debride base of Hill Sachs

- secure allograft with 2 x screws



- late resorption of graft with recurrent instability


Humeral Head Allograft Resorption


Humeral Head Osteotomy


Weber et al JBJS Am 1984

- series of 180 patients

- very low risk of recurrence


C.  Abnormal Version 


Glenoid or Head

- rarely a cause

Arthroscopic Bony Bankart Repair

Case 1: Acute Presentation


Bony Bankart Xray


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


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


Bony Bankart Fixation 7


Arthroscopic Stabilisation

Labral Repair

Arthroscopic Shoulder Stabilisation



1.  EUA


Compare both shoulders


- anterior and posterior draw

- load and shift

- sulcus sign


2.  Labral Assessment


A.  Above equator


Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability


Beware normal variations in this area


Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types


1.  Sublabral foramen


Arthroscopy Anterior Sublabral ForamenShoulder Sublabral foramen


2.  Sublabral foramen with cord like MGHL


Buford Complex


3.  Absence of AS labrum with cord like MGHL

- Buford complex


Buford Complex


B.  Below equator 


Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)


Anterior Bankart LesionShoulder Anterior Bankart


C.  Exclude HAGL


Assess anterior IGHL attachment to humeral neck


Normal IGHL Humeral Attachment


D.  Posterior Labrum


Always assess

- place camera through anterior portal


Arthroscopy Posterior Labral Tear


3.  Bony Assessment


A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?


Shoulder Anterior Glenoid DeficiencyGlenoid Bone Loss


Glenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 2



- anterior bony procedure


B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

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


Hill Sachs ArthroscopyHill Sachs Lesion SuperiorShoulder Engaging Hill Sachs




1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid


2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular


3.  Humeral head allograft


4.  Humeral head osteotomy


Technique Anterior Bankart Repair


Labral Repair


Set up


Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg




Shoulder Portals Labral Repair


A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work


B.  Anteroinferior Portal (AI)

- for anchor placement

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

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal


Shoulder Scope Anteroinferior Portal


Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula


Shoulder Arthroscopy Anterosuperior PortalShoulder Stabilisation 2 Anterior PortalsRotator Interval 2 cannulas



- can make rotator interval very crowded

- repair can be done through single portal


Mobilise labrum


Shoulder Scope Bankart RaspShoulder Stabilisation Labral Mobilisation


Labral mobiliser / rasp / scissors

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

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view


Shoulder Arthoscopy Bankart MobilisationShoulder Scope Bankart Mobilisation


Bony Fragments

- important to recognise




1.  Incorporate in repair

- pass sutures medially to bony fragments


2.  Remove / debride


Shoulder Arthroscopy Bony Bankart


Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs


Shoulder Stabilisation Anterior Labral MobilisationShoulder Stabilisation Anterior Labral Mobilisation 2


Labral Repair



- 2.3 or 3.2 mm bioabsorbably anchors


Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point


Arthroscopy Bankart Anchor Drill GuideInferior Glenoid Anchor


Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

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

- retrieve through portal

- retrieve suture posterior to anterior through portal


Shoulder Bankart Repair Suture PasserShoulder Instability inferior Suture passage


Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect


Arthroscopy Anterior Bankart Repair


Remaining anchors

- 5 mm apart

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

- up to glenoid equator

- usually three in total


Shoulder Bankart RepairShoulder Scope Bankart Repair 2


Additional Issues / Continued Instability


Capsular Shift

- take bite of capsule with suture passer, then labrum


Shoulder Instability Capsular Plication



- contributes to inferior instability

- requires repair


Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30o ER

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


- must do last




Primary Arthroscopic Stabilisation


Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

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


Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability


Arthroscopic v Open Bankart Repair


Bottoni et al Am J Sports Med 2006

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

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

- open took significantly longer and was associated with decreased ER


Revision of Failed Arthroscopic Stabilisation


Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

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


Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence

Glenoid Allograft / Autograft

Distal Tibial Allograft




Bony defects > 30 %



- Latarjet - may be insufficient for lesions in the region of 50%

- Iliac crest - associated with high incidence of OA
- distal tibial allograft - radius of curvature matches glenoid highly


Distal Tibial Allograft 1Distal Tibial AllograftDistal Tibial Allograft 3


Humeral Head Autograft


After humeral head resurfacing


Chronic Anterior DislocationHumeral Head Autograft to Glenoid


Humeral Head Autograft to GlenoidHumeral Head Autograft


DefinitionHAGL Arthroscopy


Humeral Avulsion of Glenohumeral Ligament




Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%


Bhatia KSSTA 2012

- 10% incidence of HAGL


Bigliani et al J Ortho Research 1992

- cadaveric dislocations

- 25% HAGL


Why the difference with cadavers

- ? differences in tissue

- HAGL lesions heal / don't always cause instability




Bony avulsions (BHAGL)


Soft tissue

- humeral

- humeral and bankart (floating)

- posterior / Reverse HAGL




Pouliart J Should Elbow Surg 2006

- cadaveric study

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






Shoulder MRI Normal Humeral IGHL InsertionMRI Normal IGHL



- J sign








Normal Humeral Attachment IGHL








1.  HAGL


Open Technique


Detach lower half SSC

- L Shaped tenotomy

- repair IGHL to surgical NOH


Arthroscopic Technique



- 70o scope

- 5 o'clock portal through SSC with arm adducted

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

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

- may use suture passers from posterior portal




2.  Bankart + HAGL (Floating)



- arthroscopic repair both

- open repair both

- arthroscopic repair bankart, open HAGL

- arthroscopic repair bankart, leave HAGL


Kim et al Arthroscopy Supplement 2006

- all arthroscopic, 8 good results


Rhee et al J Should Elbow Surg 2007

- 4 floating HAGL, open treatment

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


Bhatia KSSTA 2012

- subscap sparing approach in 7 patients

- good outcome


Latarjet / Bristow





Non-anatomical bony block 

- transfer of coracoid process through subscapularis

- dynamic anteroinferior musculotendinous sling

- provides subscapularis tenodesis

- preventing lower portion from displacing proximally as arm abducted

- when shoulder in vulnerable position abduction and ER


BristowBristow CT




1.  Contact Sportsman

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

- football, basketball


2.  Large bony bankart

- > 25 - 30%


Large Bony Bankart CT0001Large Bony Bankart CT0002


Glenoid bony defect



Large Bony BankartInverted Pear Glenoid


3. Large Hill Sachs

- prevent engagement


Large Hill SachsEngaging Hill Sachs


4.  Poor soft tissue

- multiple dislocations

- anterior labrum very poor quality


5.  Revision surgery

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




1.  Loss of ER 12-20°

- problem if throwing athlete

- subscapularis is relatively shortened 


2.  Screw problems 2-14%


3.  Instability 1-20%

- does not address bankart pathology

- difficult to revise with scarring in abnormal positions 


4.  Injury MCN





- correct positioning of transferred coracoid process critical to success 

- must be near but not over anterior glenoid rim


Good results can be correlated with


1. Coracoid process < 5 mm medial to glenoid rim

2. Coracoid positioned inferior to transverse equator of glenoid

3. Bony union develops between coracoid & scapula

4. Fixation screw purchases posterior glenoid cortex

5. Screw does not penetrate articular surface




Difference from Bristow


Transfers larger fragment

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


Latarjet APLatarjet Lateral



- large > 20-25% bony Bankart

- revision surgery

- contact athlete


CT Large Bony Bankart



- ? throwing athlete

- can lose considerable ER






Deltopectoral approach

- divide clavipectoral fascia at lateral edge of conjoint




Identify coracoid

- use fang retractor on superior surface to identify entire coracoid

- strip Coracoacromial ligament off lateral coracoid

- take pectoralis minor off medially


Divide coracoid

- 3 cm long

- use 90o oscillating blade on microsagittal saw 100

- medial to lateral


Prepare coracoid

- release conjoint for length, identify and protect MCN

- pect minor surface will be placed onto glenoid

- remove cortex with burr

- opposite side clear soft tissue with diathermy

- hold coracoid with Kocher forceps

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

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

- 2 x 2.5 mm drill holes, tap, countersink


Deep Approach



- identify 3 sisters inferiorly


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

- at muscle is easier to take off capsule

- also want to be inferior

- do so by inserting scissors and opening blades vertical

- use sponge to separate from capsule

- insert fang superiorly / blunt homan medially for view


B.  Take down superior half of SSC

- repair later



- feel joint line

- 2 x stay sutures 2 ethibond superiorly and inferiorly

- these must be medially over glenoid

- then divide capsule vertically with knife medial to stay sutures

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

- this prevents IR contracture


Dissect capsule from SSC

- inferiorly

- medially

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

- may be easier to do this after osteotomy coracoid

- use scissors to dissect capsule superiorly

- beware inferiorly as AXN here



- remove retractorr

- insert fukuda to expose humeral head, joint, glenoid

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


ORIF Bone Block


Bone block

- clear glenoid 3 - 6 o'clock

- need medial area to place bone

- can use burr

- place bone on glenoid using Kockers to hold

- 2 x drill bits, leave first one insitu

- bone must not overhang medially

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


Latarjet Scapular LateralLatarjet Axillary LateralLatarjet AP


Capsule repair


Remove Fucuda

- find capsue with stay sutures

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

- pass in mattress formation through capsule

- can use Depuy Mitek Suture grasper

- pass this through capsule lateral to medial, grasp suture

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




Burkhart et al Arthroscopy 2007

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

- 4.7% recurrence rate

- 5o loss or ER


Boileau et al Arthroscopy 2010

- arthroscopic Latarjet

- 6/47 had to be converted to open

- no recurrence of instability at 16 months

- 1 bony block fracture and  7 migrations

- potentially dangerous and difficult procedure




Failure of fixation


Non union of coracoid

- need to carefully prepare both surfaces

- good compression


Suprascapular nerve injury

- screws too long, or too superior



- bone block too medial



- too high, can dislocate under bone block

- too low, can dislocate over bone block


Failed Latarjet APFailed Latarjet Lateral


Open Bankart Repair



Repair of the anterior capsule & avulsed labrum to anterior glenoid 

- anatomic repair


Usually combined with a capsular shift




Bony bankart > 25% glenoid





- beach chair position

- arm free

- Mayfield head ring / Spyder and Tmax




Can perform axillary incision

- in axillary fold

- mobilise skin to gain view

- more cosmetic scar

- more difficult visualisation


Axilary Incision 1Axillary Incision 2


Superficial dissection

- deltopectoral approach

- cephalic vein lateral with deltoid

- divide clavipectoral fascia

- mobilise lateral aspect conjoint tendon

- insert shoulder retractor deep to conjoint

- expose subscapularis with three sisters inferiorly


Increase exposure

- +/- partially detach conjoint tendon from coracoid

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

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


Deep Dissection Options



Always leave inferior 1/4 of SSC

- protects AXN


L shaped incision in SSC / Capsulotomy 



Mark lower 3/4 of SSC

- ER shoulder

- use knife to divide muscle belly transversely

- expose capsule underneach

- use Cobb / dissecting scissors

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

- open interval further by spreading forceps

- tagging sutures in SSC medially (artery clips)

- divide SSC tendon vertically down onto forcep protecting capsule

- carefully elevate SSC from capsule medially using Cobb


Separate vertical incision in capsule

- right on humeral insertion

- superior and inferior

- stay on articular margin at all times

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

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

- T shaped capsulotomy used for MDI



- insert Fukuda retractor to expose joint

- displaces head posteriorly, exposes labrum

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

- labrum mobilised

- bony glenoid roughened to bleeding surface

- suture anchors at 3, 4 & 5.30 

- sutures passed through labrum and capsule


Capsular plication / shift as required

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

- check ER with arm adducted and abducted

- need 50% of normal ER / other side


Tie medial labral / capsular sutures

- recheck ER as above


Subscapularis repaired / close rotator interval if shoulder still loose



- shoulder immobiliser for 6/52 with pendulars

- no ER

- elbow & hand exercises

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

- muscle strengthening at 3/12

- return to sport at 6/12




Rowe et al JBJS Am 1978

- classic quoted paper

- 5 recurrences in 145 patient(3.5%)


Flatow et al Orthopedics 2006

- 41 open stabilisations followed for average 6 years

- one recurrence

- average loss of ER 4o





Other Surgical Techniques





Plication subscapularis & capsule




Loss ER 

Secondary OA if ER < 0°





- will force head out posteriorly




Divide SSC 2.5cm from insertion 

- may divide capsule in same plane

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

- double breast medial muscle over lateral stump

- limit ER to neutral




Kiss et al J Should Elbow Surg 1998

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

- 11% redislocation rate

- 29% moderate and with 1 severe OA

- 11% pain at rest

- average loss of ER 23o

- 83% fully satisfied






Lateral advancement of SSC and capsule

- transfer of subscapularis from LT 

- across bicipital groove to GT

- Magnusson recommended distal transfer as well to allow subscapular sling


Bone Block Procedure




Transfer of bone graft to anterior glenoid rim

- Eden-Hybinette & Oudart procedures




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


Osteotomy Humeral Head / Glenoid


No evidence to support either in most circumstances

- Glenoid neck osteotomy high rate of serious complications



- malunion post fracture


Glenoid MalunionGlenoid Osteotomy









Engaging Hill Sachs


Engaging Hill SachsEngaging Hill Sachs


Engaging Hill Sachs 1Engaging Hill Sachs 2





1.  Insert Hill Sachs anchors before performing bankart repair

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

- increases room to more

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


Posterior portal glenohumeral jont

- camera anterior portal

- debride Hill Sachs


Hill Sachs DebridementRemplissage Anchors 1Remplissage Anchor 2


Insert 2 x anchors

- insert both via posterior portal

- leave one set of sutures out through portal

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

- use bird beaks or suture runner


Remplissage Anchors


Subacromial tying

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

- redirect posterior portal into subacromial space

- camera via lateral subacromial portal

- debride posterior subacromial space carefully to find sutures

- may want to place suture savers over sutures


Subacromial sutures



- separate with birds beak

- tie these knots (white) directly


Remplissage Subacromial Space


Knots / double pulley

- tie two limbs of separate anchors together

- use other limbs to oppose knots to tissue

- then tie other limbs


Remplissage Double PulleyRemplissage Subacromial Knots


Camera back into glenohumeral joint

- check capsule tied down into defect


Shoulder Post Remplissage

Revision Stabilisation

Causes for failure


1.  Patient factors


A.  Recurrent Trauma

- contact athletes higher risk


B.  MDI / Ligamentous Laxity / Voluntary dislocaters


C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow


2.  Surgeon Factors


A.  Unrecognised bony defect

- large bony bankart

- large engaging Hill Sachs


B.  Non Anatomical repair


C.  Poor sutures / poor knots / insufficient anchors


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


E.  Posterior capsular tear / incorrect diagnosis / MDI




Identify cause of recurrent instability



- traumatic or atraumatic






- large Hill Sachs

- large Bony Bankart



- assess anchor position

- reassess labral repair / integrity




Long period non operative

- best results if muscle control  and strength are optimal


Revision Options


1.  Revision arthroscopic stabilisation



- no bony defect

- poorly done original surgery

- traumatic redislocation



- repair labrum

- capsular plication

- +/- rotator interval closure


2.  Open stabilisation



- as above


3.  Laterjet



- bony defect

- large Hill Sachs


Results of revision surgery in those without bony defects


Arthroscopic revision post failed arthroscopic stabilisation


Franchesci et al Am J Sports Med 2008

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

- 1 failure


Arthroscopic revision post failed open stabilisation


Boileau et al Arthroscopy 2009

- 22 cases post Latarjet and open Bankart

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

- 1 recurrent subluxation and 2 with positive apprehension


Open revision


Levine et al Am J Sports Med 2000

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

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

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




Case 1


Recurrence of instability without trauma

- anchors very high

- into glenoid face

- MRI suggests remaining inferior bankart

- no bony deficiency, no HAGL


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


Failed Open Stabilisation MRIFailed Open Stabilisation MRI 2


Case 2


Recurrent instability

- non recognised bony defect

- revised with Latarjet


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






Locked Glenohumeral Dislocation



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

- time period is arbitary

- > 3-6 weeks




Humerus soft and osteoporotic

Significant soft tissue contractures


1.  Anterior / subcoracoid dislocation



- scarring to NV structures

- RC tears including SSC, especially > 40

- anterior glenoid wear / can have significant bone loss

- large engaging Hill Sachs / humeral head defects


2.  Posterior dislocation

- posterior glenoid wear

- reverse Hill Sach's / large anteromedial defects




Anterior 41%


Posterior 59%




Multi trauma


Poor patient mental function




Limitation ROM

History multi trauma / seizures

Previous treatment

- often have had inadequate X-rays

- extensive physiotherapy / injections




Usually some asymmetry


Some reduction ROM


Palpate humeral head anteriorly / posteriorly




Scapular AP view

Scapular lateral

Axillary lateral




Aids diagnosis and preoperative planning




Non Operative



- elderly 

- minimal functional limitation

- significant medical issues


Only operate if significant clinical problems

- anterior more difficult than posterior to solve




Closed reduction




1.  Timing 

- has been successful up to 6-8 weeks

- most successful outcomes in literature < 4 weeks


2.  Humeral head impression

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


3.  May be unstable afterwards

- need further open procedure

- need careful postoperative monitoring

- regular xray surveillance


Chronic Anterior Dislocation


1.  Large Humeral Head Defect


Hill Sach's

- posterolateral defect

- manage according to size


Defect < 40%


A.  Elevate and Bone graft defect

- < 4 weeks in young patient

- adequate bone, salvageable cartilage

- posterior approach

- split deltoid / L shaped Infraspinatous tenotomy


B. Advance Infraspinatous +/- GT

- posterior approach

- < 20% IS alone

- if larger must also take GT


Defect > 40%


A.  Allograft

- young patient

- pre-op CT to estimate humeral head size

- appropriate sized femoral / humeral head


B.  Prosthesis

- often significant OA with long standing dislocation

- anterior glenoid deficiency

- older patient

- increase retroversion of humeral component

- may need to address anterior glenoid deficiency


2.  Glenoid Deficiencies


Indicated when > 20-25% anterior glenoid eroded


Bristow / Latarjet


Glenoid Reconstruction

- humeral head

- iliac crest


Glenoid Reconstruction Humeral HeadGlenoid Reconstruction


3.  Soft tissue deficiencies 


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


4.  Rotator cuff tears


Significant issue

- if massive cuff tear, may lead to chronic instability

- very difficult to treat




50 year old, missed locked anterior dislocation one year

- head severely mis-shapen

- missing 50% glenoid

- massive rotator cuff tear



- open reduction

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

- unfortunately rotator cuff repair failed, and developed recurrent instability

- option: Reverse TSR / fusion


Locked Anterior 1Locked anterior 2Locked Anterior 3


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


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




26 year old female

- ligamentous laxity, but no previous shoulder problems

- traumatic anterior shoulder dislocation

- leading to recurrent anterior subluxation

- had an arthroscopic anterior and posterior capsular plication

- shoulder now permanently dislocated anteriorly

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


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


Locked anterior 1Locked anterior 2Locked anterior 3


Chronic Posterior Dislocations




Standard DP approach

- manage SSC depending on operative plan for humeral head defect

- open capsule

- remove any fibrous tissue in glenoid

- use lever to reduce humeral head

- usually can ignore posterior capsular detachments


Manage humeral head / glenoid defects


See Posterior Shoulder Instability


1.  Humeral Head defects


Posterior dislocation

- anteromedial


Defects < 40%


A.  Disimpaction and bone graft

- < 4 weeks, young patient

- articular cartilage must be salvageable

- via anterior approach


B.  McLaughlin

- < 20%, SSC only

- < 40% transfer SSC + LT into defect

- secure with 2 x cancellous screws


Defects > 40%


A. Allograft

- young patient


B.  Hemiarthroplasty / TSR


2.  Posterior Glenoid Deficiency


May need posterior bone graft


Luxatio Erecta



Rare, inferior shoulder dislocation




Forced abduction injury




Shoulder is hyperabducted

- humeral shaft abuts the acromion

- humeral head is levered inferiorly

- tears inferior capusle


Head becomes locked inferior to glenoid


May button hole through inferior capsule

- becomes irreducible

- need open reduction


Has tear rotator cuff / GT fracture




Tear RC

GT fracture

AXN palsy

Thrombosis axillary artery


Clinical Presentation


Patient has shoulder abducted

- has elbow flexed

- elbow resting on head




Conscious sedation

- increased abduction initially

- then adduct


Post Reduction



- assess RC / biceps



- usually recovers





Multidirectional Instability

DefinitionMDI Shoulder


Instability in at least 2 planes

- postero-inferior

- antero-inferior

- antero-postero-inferior




Recognised as a common problem 

- often misdiagnosed


Most patients athletic

- average age 24 years (15 - 54 years)




1.  Inherent ligament laxity > 50%


2.  Repetitive overuse with capsular stretch 

- microtrauma


3.  Macro-trauma < 50%




Collagen abnormality


Increased joint volume 

- 2° enlarged inferior axillary capsular pouch

- patulous anterior and posterior


Often attenuated, broad rotator interval




Often bilateral


Instability of other joints


Feeling of shoulder "slipping down" while carrying heavy loads

- inferior instability


Often recurrent subluxation with minimal trauma

- sleeping


Shoulder pain

- fatigue 

- impingement type pain with overhead activities




Ligamentous laxity 75%


Inferior instability

- Sulcus Sign +


Shoulder Sulcus Sign


Anterior instability

- anterior draw

- anterior load and shift

- anterior apprehension, positive Jobe's relocation


Posterior instability

- posterior draw

- posterior load and shift

- posterior apprehension / jerk test




Traction xray

- patient standing with 5-10 kg in each hand

- Shows inferior subluxation of head


DDx of Inferior displacement of head


Torn superior rotator cuff

Suprascapular nerve palsy

Deltoid atony eg CVA

Deltoid / axillary nerve palsy






Mainstay of treatment

- operative results poor




Minimum 12/12

- initial shoulder strengthening

- strengthen 3 parts of deltoid, cuff & scapular stabilisers

- specific programme with rope & pulleys

- combined with education program

- ~ 90 % success





- never operate on voluntary dislocator

- MDI surgery less successful than surgery for unidirectional instability

- cannot perform isolated anterior surgery

- bristow procedures etc fail as capsule remains redundant 

- anterior surgery may displace head posteriorly


MDI with traumatic anterior bankart

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

- MRA diagnosis of anterior bankart

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

- issue is whether to combine with capsular shift


Options for MDI


1. Neer and Foster inferior capsular shift

2. Arthroscopic capsular plication


1.  Open Inferior Capsular Shift ~ Neer & Foster 1980


MDI SubluxedMDI Reduced



- detach capsule from neck of humerus

- shift capsule superiorly to obliterate the inferior pouch

- decrease joint volume





- to confirm diagnosis


Deltopectoral Approach / Axillary fold



- must divide SSC separate to capsule

- need to leave capsule intact

- make horizontal incision in inferior border of SSC

- at muscular aspect

- insert curved artery forcep between SSC and capsule

- will exit at rotator interval

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

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


T shape capsulotomy of capsule

- vertical component on humeral insertion

- transverse component to midpoint glenoid

- mark with pen first

- make vertical component on articular margin

- place inferior and superior stay sutures

- make horizontal incision

- creates superior and inferior capsular flaps


Capsular Shift 1Capsular Shift 2


Inspect joint

- ensure no loose bodies

- repair bankart lesion if needed


Inferior capsular flap

- must sharp dissect capsule off inferiorly around humeral head

- protect AXN at all times

- do so by following articular margin around

- ER shoulder +++

- must get past 6 o'clock into posterior aspect

- check that traction on interior flap reduces inferior capsular pouch


Superior advancement inferior capsular flap

- tension on flap aimed at eliminating inferior pouch

- must reduce posterior capsular redundancy

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

- +/- anchors

- begin inferiorly, care with AXN

- cut and clip each sutures

- then tie all sutures togther at end


Capsular Shift 3Capsular Shift 4


Check ER

- arm adducted, check ER 45o

- arm abducted to 90o, check ER 45o


Superior flap sutured down over inferior flap

- again multiple 0 pull off sutures

- tie

- check ER as above


Check not too tight

- can dislocated posteriorly


Closure of RI

- check ER as above


Subscapularis tendon brought over & reattached to normal location

- check ER as above


Post op

- Arm immobilised in sling 6/52

- No sport for 9/12 




Bigliani et al JBJS Am 2000

- 52 shoulders with open inferior capsular shift

- approach posterior or anterior depending on greatest instability

- 96% remained stable at average 61 months

- 60% excellent and 30% good results

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


Ogilvie-Harris Br J Sports Med 2002

- contact athletes

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

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

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

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

- only 17% return to sport if bilateral procedures


MDI Pre Capsular ShiftMDI Post Capsular Shift


2.  Arthroscopic






View via posterior and anterosuperior portal

- labrum is attached

- capsule very lax


Capsular laxity 1Capsular laxity 2Intact anterior capsule and labrum


Anterior plication

- use shaver to create capsular stimulation

- don't remove or resect capsule


Option 1

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

- take bite of anterior inferior capsule with suture passer

- advance suture passer

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

- tie

- repeat x 2


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


MDI 2 bites anterior capsuleMDI 3 x anterior capsular sutures



Option 2

- anchor in glenoid

- pass stures throught capsule and labrum


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


Posterior plication

- camera inserted via anterior portal

- insert posterior cannula

- repeat inferior posterior sutures x 3


MDI Posterior capsular plication


May suture rotator interval if needed




Baker et al Am J Sports Med 2009

- 43 patients average age 19 years

- 86% return to sport


3.  Thermal Capsular Shrinkage


Recognised as poor procedure




Miniaci et al JBJS Am 2003

- 19 patients with MDI

- 9 recurrent instability

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

- worse results in posteroinferior compared with anteroinferior



Posterior Dislocation

Chronic Posterior Dislocation AP





- 2% of acute dislocations


Often missed

- < 1/ 52 25%

- < 6/52 25%

- < 6/12 25%

- > 6/12 25%




Usually secondary major trauma


- Seizures


- Electrocution

- Alcohol-related injuries




Loss of ER


Arm kept IR

- Hold arm across chest 


Beware of young patient with arm across chest & limited ROM

- don't think frozen shoulder only


AP Xray


1.  Light-bulb sign 

- globular head 2° IR


Posterior Shoulder Dislocation Light Bulb Sign


2.  Vacant Glenoid Cavity

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


Posterior Shoulder Dislocation AP Non Concentric GHJ


Axillary Xray



- humeral head posterior to glenoid


Look for reverse Hill- Sachs


Posterior Shoulder Dislocation Axillary Lateral


Scapular lateral


Can be missed if any obliquity to Xray

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

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


Posterior Shoulder Dislocation LateralPosterior Shoulder Dislocation Scapula Lateral


CT scan


A.  Confirms dislocation


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


B.  Quantifies humeral head defect 

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


Humeral Head Defect



- measured as a percentage of the articular surface


Case 1


CT Chronic Posterior Humeral Head DefectPosterior Shoulder Dislocation Anterior Hill Sachs


Case 2


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




Posterior Shoulder DislocationPosterior Shoulder DislocationPosterior Shoulder Dislocation 2


Beware Chronic Case


Chronic Posterior Shoulder Dislocation MRI AxialChronic Posterior Shoulder Dislocation MRI Sagittal




Closed reduction



- injury more than 6 /52 ago

- large posterolateral defect locked on glenoid rim

- > 40% defect (will be unstable)




Consent for

- open reduction

- +/- bone grafting

- +/- McLaughlin procedure



- arm adducted

- arm flexed to 90o

- increasing IR first to unlock head

- traction


Unstable closed reduction 

- may have to use gun slinger cast

- arm abducted 90o and ER


Post Reduction


Assess anterior Hill Sachs


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


Open reduction



- failure closed reduction

- inability to maintain reduction in gunslinger

- chronic posterior dislocation




1.  Anterior deltopectoral approach

- reduce humeral head


2.  Address instability / manage anterior humeral head defect


Humeral head Defect Management


1.  HS < 25% 



- treat non operatively if stable

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

- +/- posterior labral repair


Reverse Hill Sachs less than 25 percent


2.  HS > 25%



- transfer SSC +/- LT

- osteochondral allograft young patient

- hemicap / resurfacing older patient


Reverse Hill Sachs Defect greater than 25%


3.  HS > 40%



- hemiarthroplasty / TSR (older patient)

- osteochondral allograft (younger patient)


Reverse Hill Sachs greater than 40 percent


SSC +/- LT transfers




SSC transfer / McLaughlin

- makes defect extra-articular


SSC + LT / Neer modification



- best for small defects = 25%

- young patient



- may weaken IR


Osteochondral Reconstruction


Shoulder McLaughlin APShoulder McLaughlin Lateral


Reverse Hill Sachs AllograftReverse Hill Sachs Allograft 2




Diklic et al JBJS Br 2010

- 13 patients with anteromedial defects between 25 and 50%

- all chronic / missed injuries

- open reduction

- SSC divided 1 cm from insertion, separated from capsule

- posterior labral repair / posterior plication if required

- femoral allograft inserted and fixed screws

- ER brace post op

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


Hemiarthroplasty / TSR



- older patient

- humeral defect > 40%



- may get recurrent posterior instability

- may have posteror glenoid bone defect



- anterior SSC Z lenthening

- posterior capsular plication +/- advancement IS / Tm

- glenoid poly insertion if posterior glenoid wear

- decreasing humeral head retroversion to 20o

- gunslinger post op for 6 weeks




Sperling et al J Should Elbow Surg 2004

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

- mix of hemiarthroplasty and TSR depending on state of glenoid

- some posterior plications performed

- 2 patients had recurrent posterior instability

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

- one hemi was revised to TSR with plication

Posterior Instability



Patients usually complain of subluxation rather than dislocation

- rarely requires reduction


Different entity to acute posterior dislocation usually








1.  Ligamentous laxity > 50%

- commonly associated with MDI

- posterior only 20%

- posterior & inferior 20%

- posterior / inferior & anterior 60%


2.  Trauma


A.  Repetitive microtrauma 

- common


B.  Macro-trauma 

- uncommon

- seizures

- electrocution


- alcohol related injuries





1.  Capsulo- ligamentous


A.  Reverse Bankart lesion 

- uncommon

- detached posterior labrum < 10%


B.  Capsular laxity

- much more common


C.  Posterior IGHL avulsion

- reverse HAGL


2.  Bony


A.  Humeral Head Defects  

- reverse Hill-Sachs lesion 

- defect in Ant humeral head

- seen in traumatic dislocations / chronic posterior dislocation

- can make humerus unstable

- compared with anterior Hill-Sachs which rarely does


CT Humeral Head Defect


B.  Posterior glenoid deficiency

- seen in traumatic / chronic dislocations


Posterior Glenoid DeficiencyPosterior Glenoid Deficiency Sagittal


C.  Humeral head / glenoid retroversion


Shoulder Posterior Instability Glenoid Retroversion




Must exclude voluntary dislocator


History of ligamentous laxity / other problems




Must assess for

- MDI / Ligamentous Laxity

- voluntary dislocator


Tender posterior joint line 

- fairly specific for OA rather than instability



- loss of ER (in locked posterior dislocation)


Ligamentous laxity


Sulcus sign

- indicates MDI


Anterior apprehension

- indicates MDI


Posterior stress test 

- supine

- adduct, forward flex and IR arm

- posterior force

- apprehension test


Load and Shift / Posterior Drawer


Altchek Grading


Grade 0       No translation

Grade 1+     Up to glenoid rim

Grade 2+     Beyond rim with spontaneous reduction

Grade 3+     Translation beyond rim without spontaneous reduction




1.  Define extent of Hill Sach's lesion


2.  Glenoid bone defect


3.  Glenoid version


Posterior Instability Glenoid Retroversion




Posterior bankart lesion


Shoulder MRI Posterior Labral Tear


Posterior labral cysts


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






Not infrequently little functional problems


Prolonged initial physical treatment for all patients

- minimum 12 months

- treat similar to MDI patients

- Matson & Rockwood 80-90% success rate





- failed non-operative management

- moderate to severe disability




- voluntary dislocator

- ligamentous laxity

- minimal functional impairment




1.  Posterior Bankart lesion



- arthroscopic / open reconstruction


Posterior Labral Tear


Failure / Bony Block Revison

- posterior approach

- detach infraspinatous

- expose capsule

- divide capsule medial to glenoid

- take 2 cm long x 1 cm thick iliac crest

- secure to glenoid with 2 x small fragment screws

- reattach capsule lateral to bony block


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


2.  Capsular laxity



- posterior capsular shift arthroscopic or open

- reverse Putti-Platt


Open capsular plication


Bigliani and Flatow July 1995

- 35 patients

- If primary operation 23 of 24 successful

- 89% stable at 5 yrs


Reverse Putti-Platt



- posterior approach

- posterior imbrication of IS & Tm 

- combine with posterior capsule imbrication

- shorten tendon 1cm = 20°

- limit IR to 20o


3.  Humeral Head Defect


Humeral Head Anterior Hill Sachs CT


1.  HS < 25% 

- leave


2.  HS > 25%

- transfer SSC + LT (McLaughlin)

- OC allograft


3.  HS > 40%

- hemiarthroplasty / TSR (older patient)

- OC allograft (younger patient)


4.  Posterior Glenoid Defects



- posterior glenoid bone graft


Posterior Glenoid Bone BlockPosterior Bone Block CT




Meuffels etal JBJS Br 2010

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

- 36% had had recurrent dislocation

- half would not have the surgery again

- all had evidence of OA


5.  Retroverted Glenoid Version / Static Posterir Shoulder Subluxation



- posterior shoulder subluxation > 65%

- shoulder OA

- young age

- glenoid osteotomy


Static Posterior Shoulder SubluxationGlenoid Retroversion SPSSSPSS MRISPSS Calculation



- posterior opening wedge glenoid osteotomy

- rarely indicated & technically hard



- congenital retroversion of glenoid > 30o



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

- must prevent penetration of glenoid



- anterior impingement of subscapularis on coracoid causing pain

- anterior subluxation of humeral head

Surgical Techniques

1.  Arthroscopic Posterior Bankart Repair +/- Capsular Plication


Posterior Labral TearPosteior Labral Repair




Posterior Portal

- make slightly inferior and lateral compare to normal

- inspect joint

- place anterior portal +/- ASL portal


Remove cameral and place thorough anterior portal

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


Often need second portal lateral and inferior to place inferior anchor

- can use simple stab incision here


Assess labrum and capsule

- repair posterior bankart

- plicate redundant / patulous capsule




Kim et al JBJS Am 2003

- 27 patients with unidirectional posterior instability

- all with labral injuries, most with capsular laxity

- all had arthroscopic posterior labral repair and capsular shift

- only one recurrence


Pennington Arthroscopy 2010

- 28 athletes with pure posterior labral pathology

- 93% return to sport


Bradley et al Am J Sports Med 2006

- 91 athletes with 100 shoulders with unilateral posterior instability

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

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

- remainder combination injuries including partial labral tears

- 8% failure rate, all with capsular laxity

- patients had evidence of chondrolabral retroversion


2.  Open Posterior Capsular shift 


Open Technique



- lateral



- vertical incision

- posterior axillary fold


Shoulder Posterior Approach


Superficial dissection

- split deltoid to expose infraspintous

- elevate IS off capusle

- L shaped incision infraspinatous after tagging sutures medial

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



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

- axillary nerve through quadrangular space below Tm



- labral detachment reattached if present

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

- inferior capsule shifted superiorly

- reinforced with superior limb of capsule

- may augment with IS tensioning


3. Posterior Glenoid Osteotomy


Reserved for in setting of severe posterior retroversion with instability


Posterior glenoid osteotomy






Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2




1. Establish portals


A.  Posterior portal for viewing


B.  Anterior portal

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

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


SLAP repair anterior portal


C.  Anterosuperolateral portal / Wilminton for insertion of anchors

- insert spinal needle first

- anterolateral border acromion

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

- check with needle

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

- passes through supraspinatous

- use knife to cut in line with fibres

- insert portal


SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals


2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone


Shoulder SLAP Preparation Base


3.  Anchors


Drill and insert via Wilminton portal

Usually 3 anchors is a minimum



- insert anchor

- suture through each cannula

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

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


SLAP Anchor InsertionShoulder SLAP Repair Suture Management


Anterior anchor

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

- retrieve sutures and tie from port of Wilmington


SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2


SLAP Anchor 1SLAP Tie anterior anchor


Posterior 2 anchors

- pass suture passer under biceps


SLAP Vertical MattressSLAP Second Anchor


SLAP third anchorSLAP 3 anchor repair


Can suture Portal of Wilminton if desired


Portal WilmingtonWilminton Repair 1Wilminton Repair 3


4.  Dfficult posterior anchors


Camera through anterior / anterosuperiorlateral portal


A.  Place anchor through posterior portal

- does not always give good angle


SLAP repair posterior portal


B.  Trans infraspinatous Portal


SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair


Biceps Tenodesis




- intra-articular

- suprapectoral



- suprapectoral

- subpectoral


A.  Arthroscopic Intra-articular


Biceps Tenodesis Intra articular



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



- anterior portal + portal of Wilmington

- debride capsule and biceps with shaver so will heal

- use curved suture passer with no 1 PDS

- suture shuttle no 2 fibre wire

- divide 90% biceps insertion so will rupture in time

- allows healing of biceps to capsule


Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture


Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut


Attempt Figure 8 Suture Configuration


Biceps Tenodesis Step 1Biceps Tenodesis Step 2


B.  Arthroscopic Suprapectoral Technique


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


A.  Birds Beak Passer with 2 ethibond loop

- pass loop through intact tendon at entry through RC interval

- retrieve loop out through portal and lock

- this gives strong hold on tendon


B.  Pass 18 G spinal needle through biceps tendon

- thread 1 PDS or nylon

- retrieve both suture ends via portal in rotator interval

- secure with half hitches

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


Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon


2.  Resect tendon with electrocautery at insertion


Arthroscopy Biceps Tenotomy


3.  Make portal over biceps interval into subacromial space

- release biceps tendon with electrocautery or arthroscopic scissors


4.  Secure tendon

- make drill hole

- insert tendon

- secure with biotenodesis screw

- multiple techniques with specifically designed equipment


C.  Open Technique for Intact Biceps


1.  Divide biceps arthroscopically

- may wish to place stay suture first to avoid retraction

- biceps normally has vinculae preventing complete retraction into arm


2.  Suprapectoral

- deltoid split

- between anterior and middle parts

- find biceps in groove

- pull out of wound and whip stitch with heavy suture

- drill appropriate size tunnel for fixation screw

- multiple biceps tenodesis devices

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


3.  Subpectoral

- medial incision in arm

- below inferior edge of pectoralis major

- find biceps tendon

- whip stitch

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


Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis


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


1.  Locate biceps




A.  Suprapectoral

- best to make deltopectoral approach

- biceps may be futher retracted


B.  Subpectoral approach


2.  Fixation

SLAP lesion

DefinitionMRI SLAP Tear


Superior labrum anterior & posterior


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




2 groups


1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability


2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis




Three mechanisms


1.  Compression force applied to GHJ


- commonest

- arm in abduction & forward flexion

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


2.  Traction on Arm

- sudden pull on arm

- grab while falling


3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading




Pain with overhead activities


Catching or popping with overhead activities


Acute trauma


Mimics impingement




Speed's Test 

Yergason's Test


O'Brien's test


Causes impingement of biceps on anterosuperior labrum


1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain


2.  Relieved when same again but with ER

- i.e. no pain with thumbs up


McMurray's Shoulder test


Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click




See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant


MRI Slap with SS tearMRI Anterior Bankart


Supralabral ganglion cyst

- associated with posterior SLAP tears


Normal Arthroscopy


Normal Biceps Insertion


Arthroscopic Classification Snyder


Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 


Arthroscopy Meniscoid Biceps Insertion


Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   



- anterior

- posterior

- anterior and posterior


SLAP arthroscopyShoulder Scope SLAP Type 2


Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid


Shoulder Scope Type 3 SLAP


Type 4

- bucket handle tear of superior labrum with part of biceps

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


Type 4 SLAP Tear extends partially into bicepsSLAP Type 4


Type 5 - 7 added by Gartsman


Type 5
- SLAP 2 with anterior bankart extension


Type 6

- SLAP 2 with free flap of meniscal tissue


Type 7

- Slap 2 with anterior bankart extension and into MGHL


Normal Variations of the Superior Labrum


The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair


Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion


Davidson et al Am J Sports Medicine 2004

- described normal variations


1.  Triangular


2.  Bumper

- lump of fibrous tissue


3.  Meniscoid

- labrum extends down over glenoid face




Non Operative



- physio





Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy




1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy




1.  Older patient with RC tear and SLAP


Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group


2.  Repair v Tenodesis Type II SLAP


Boileau et al Am J Sports Med May 2009

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

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

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


Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

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


3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist


MRI SLAPMRI Anterior Bankart


Management Algorithm


Type 1


Debride labrum


Type 2


A.  Arthroscopic repair


B.  Tenotomy / tenodesis


Type 3


Debride bucket handle labrum


Type 4


Remove labral flap


Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis


Types 5 - 7

- associated with instability

- repair as per treatment of instability

Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps


LHB primary function is humeral head depressor


Also accelerate / decelerate arm in overhead sports




Biceps problems usually occur with other pathology 

- rotator cuff / instability


3 main problems


1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture



- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps


2.  Instability


Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament


Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear


Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears


3.  Disorders of the origin (SLAP)


4.  Hourglass Biceps


Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

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

- requires double release  / tenotomy / tenodesis





- from postero-superior labrum and supraglenoid tubercule


Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament




Tenderness over biceps tendon crucial



- Popeye appearance


Popeye Sign BicepsPopeye Biceps



- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness



- elbow flexed and pronated

- resist supination

- pain over LHB


O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up






MRI Enlocated Biceps Tendon




Biceps Tendonitis MRI


Tendonosis / thickening


Biceps Tendinosis MRI


Medial Subluxation


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






Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit


Mild Tendonopathy


Biceps Tendonopathy Grade 2 Arthroscopy


Moderate Tendonopathy


Shoulder Biceps Moderate Tendonopathy


Severe Tendonopathy


Biceps Tendonopathy ArhroscopyBiceps Tear near complete


Dislocated Biceps in Presence of complete SSC Rupture


Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon




1.  Tendonitis


Non Operative


As per rotator cuff / impingement


- physio


Surgical Options


1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament


2.  Tendon Fraying / Tendinosis / Rupture


Grade tendon integrity


I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture


Management Strategy


I & II

- SAD & debride tendon 



- SAD & biceps tenodesis / tenotomy


Tenotomy v Tenodesis


Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

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


Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

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

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




Popeye deformity


Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men


Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis




Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength





- young patient grade II, III, IV

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



- screw prominence / pain

- failure of fixation



- arthroscopic

- open

- see techniques




Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral


Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony




Suprapectoral or subpectoral


Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury


3.  Subluxation




Usually medial from SSC tear

- must manage LHB or SSC repair will fail




1.  Tenodesis / Tenotomy + SSC repair


2.  Stabilisation + SSC repair



- can get stenosed painful tendon  


Maler et al JBJS Am 2007

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

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US








Axillary Nerve Lesions



Terminal branch of the posterior cord

- lateral to radial nerve

- behind axillary artery

- runs over inferolateral border of SSC

- enters quadrangular space


Quadrangular space

- SSC superiorly anterior

- T major inferior

- T minor superiorly posterior

- long head triceps and humerus


Divides into anterior and posterior branches


Axillary Nerve Sagittal MRI 1Axillary Nerve Sagittal MRI 2


Anterior branch

- curves around SNOH

- deep to deltoid

- 4-7 cm inferior to corner acromion

- supplies anterior and middle portions deltoid


Posterior branch

- supplies T minor and posterior deltoid

- sensory branch


3 distinct fascicles

- T minor

- deltoid (supero-lateral)

- superior lateral cutaneous branch




1.  Traumatic

2.  Iatrogenic

3.  Quadrilateral Space Syndrome

4.  Brachial Neuritis

5.  SOL


1.  Traumatic


A. Shoulder Dislocation

- 10-20% incidence post dislocation


Blom et al Acta Chir Scand 1970

- 9 complete and 15 partial lesions

- all recovered within 1 - 2 years


Gumina JBJS Br 1997

- high rate in elderly > 40 (50%)

- all recovered by 3 years

- high rate of RC (20%)


B. Proximal Humeral fracture


C. Brachial Plexus injury

- rarely isolated

- in conjunction with other injuries

- upper trunk


D.  Blunt trauma to deltoid


2.  Surgery


A.  Deltoid-Splitting approach

- lies 5cm lateral to anterolateral corner of acromion


B.  Deltopectoral approach

- undue care at inferior level of SSC


3. Quadrilateral space syndrome



- Compression in position ER and abduction



- get pain and paraesthesia in shoulder 

- can have chronic dull ache



- usually no deltoid atrophy or sensory changes





- normal



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



- may shows changes in deltoid and Tm



- usually just observation

- occasionally need to decompress scar tissue or fibrous band


4.  Parsonage-Turner Syndrome


Brachial neuritis

- spontaneous development severe shoulder pain

- then develop loss of motor function

- usually also LTN, SS nerve, but occasionally isolated



- can treat with steroids

- usually good prognosis


5.  Nerve compression from mass effect



- aneurysm, tumour




No history trauma

- suspect mass effect / quadrilateral space syndrome / brachial neuritis


Pain then loss of function

- suspect brachial neuritis


History dislocation




Deltoid Wasting


Wasting Deltoid


Weakness of shoulder abduction


Numbness in Regimental patch 

- variable




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

- will also have injuries to


A.  SS nerve

- IS / SS

- remember dislocation may cause RC tear


B.  Subscapularis


C.  Biceps


2.  Posterior cord injury

- will also have injuries to


A.  Radial nerve

- triceps, WE, FE, thumb extension


B.  Thoracodorsal

- Lat Dorsi


C.  Upper and lower subscapular





Diagnose higher lesion

- reference point for recovery




Mass lesions

Atrophy of T minor

Assess RC 


Operative Management



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

- open wounds / stab wounds




Best results 

- reinnervation must occur before one year

- otherwise get degeneration of NMJ

- i.e. surgery must occur by 9 months




No muscle transfer for deltoid

- nerve repair

- neurolysis

- nerve grafting

- nerve transfer


1.  Neurolysis



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



- identify nerve

- use nerve stimulator intra-operatively

- stimulation of nerve will cause muscle contraction if intact

- uncommon


2.  Neurorrhaphy 



- laceration



- direct repair of laceration

- if in first few weeks


3.  Nerve grafting



- neuroma usually at or in quadrilateral space


2 Incision Technique


Sural nerve graft

- anastomose anteriorly, then pass through

- anastomose posteriorly


Lateral decubitus

- access anterior and posterior shoulder

- allows sural nerve harvest


Deltopectoral approach

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

- must release conjoint tendon and P minor

- do so 1cm from origin

- expose axillary, radial and MCN

- use nerve stimulator to ensure nerve not working

- identify and protect axillary artery and vein

- if deltoid active, neurolysis


Identify neuroma

- if deep

- posterior approach to shoulder


Posterior vertical incision

- lateral border acromion to posterior axillary crease

- mobilise inferior border deltoid superiorly

- find nerve as exits quadrilateral space

- identify deltoid fascicle using nerve stimulator




Allnot Int Orthop 1991

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


4.  Neurotisation / Nerve transfer



- use branch of radial nerve

- transfer into motor branch axillary

- single incision



- posterior longitudinal approach to arm

- find AXN under wasted deltoid, exiting above T Major

- identify anterior branch of AXN going into muscle

- ensure not branch to T minor or sensory branch

- develop interval between long and lateral heads

- find radial nerve in groove between medial and lateral heads

- will be exiting below T Major between long and humerus

- harvest branch to long or medial head triceps

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

- check with nerve stimulator

- repair with 9.0 nylon under microscope




Leechavengvongs et al J Hand Surg Am 2003

- all 7 patients had M4 power

- 5 excellent and 2 good results

- no demonstrable loss of elbow extension power

Constant Shoulder Score


Subjective Assessment 35 points





- work

- recreation

- sleep


Ability to work at specific level

- waist

- chest

- neck

- head

- above head


Objective Assessment 65 points











Pectoralis Major Rupture



Usually related to sporting activities including weight lifting

- bench press most common 

- higher risk with steroid use




Peak age 20 - 40


Often unrecognised





- intra-muscular

- MT junction

- tendon avulsion

- 2:1 tendon avulsions compared with musculotendinous junction


Partial or complete


Sternal / clavicular heads or both




Clavicular head

- medial clavicle and upper sternum

- inserts at lowermost aspect of biciptial groove


Sternal head

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

- inserts at uppermost aspect of bicipital groove




2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa


Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head


Nerve supply


Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head


Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor



- powerful adductor, flexor and internal rotator




Usually recall incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising

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


Acute Pectoralis Major Tear




Asymmetry chest wall


Pectoralis Major RupturePectoralis Major Tear Chronic


Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction


Pectoralis Ruture Palpable Cord


Resisted adduction is weak

- hand on hip

- feel tendon insertion




Useful in the acute setting


Will also identify site of rupture and amount of retraction




Non Operative



- partial tears

- muscle belly tears

- elderly






Pochini et al Am J Sports Med 2010

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

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

- strength in non operative group 50% of other arm




Chronic ruptures

- best to repair within 8 weeks

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



- may wish to have allograft / achilles tendon available

- especially needed if tendon has retracted beyond nipple line




Deltopectoral approach / axillary fold incision


Anterior lamina fibres of clavicular head are usually intact

- pectoral fascia also usually intact

- blunt dissection medially under clavicular head to find sternal head




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

- Krackow suture in tendon with no 5 non absorbable

- repair through drill holes

- +/- suture anchors

- + / - direct suture of MT junction


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


2.  Foot print technique

- roughen area of insertion lateral to LHB / osteotome

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

- pass through tendon and suture down


3.  Allograft reconstruction

- fascia lata / tendo achilles

- pass graft through pec major

- double over and insert into bone tunnel


Post op

- sling 6 weeks

- ROM 6 weeks

- strengthening at 3/12





- higher than normal risk due to proximity to axilla


Humerus fracture

- case report with bone trough


LHB rupture

- case report



- most common

- up to 7%







Shoulder Xrays

AP Shoulder



- in plane of thorax

- oblique of GHJ


Shoulder AP Xray


AP in plane of scapula



- angle 45o lateral

- allows estimation of glenohumeral space


AP Plane Scapula




Demonstrates Hill Sach's and other humeral head morphology


Scapular lateral


Patient erect

- affected shoulder against plate

- rotate other shoulder 45o out of way

- beam aimed along spine of scapula


Scapular LateralScapula Lateral Posterior Shoulder Dislocation


Axillary lateral


Patient seated

- arm abducted

- plate under axilla

- beam angled down towards shoulder


Axillary Lateral XrayAxillary Lateral Posterior Subluxation


Supraspinatous outlet view


For acromial morphology and impingement


Similar to scapular lateral

- tilt beam caudal 10o


Supraspinatous Outlet View


West Point View


Variation axillary lateral

- tangential view anterior / inferior glenoid 

- for bony bankart


Patient prone with arm hanging off bed

- plate superior to shoulder

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


Westpoint view Hill Sachs


Garth View / Apical Oblique


True AP with 45o caudal tilt

- to show anterior / inferior capsule 

- bony bankhart / Hill Sachs

- standing with plate behind joint

- 45° caudal tilt / 45° in coronal


Garth XrayShoulder Garth View


Stryker Notch view


Patient supine with cassette posterior to shoulder

- hand on head, elbow straight up

- beam 10o cephalic aiming at corocoid


Demonstrates Hill-Sach's


Stryker Notch View Hill Sachs


Zanca view




Patient erect with cassette behind shoulder

- aim beam at ACJ 10 - 15o cephalic

- half strength to not overexpose ACJ


Zanca View


Serendipity view





- prone with cassette under chest

- aim beam 40o cephalic


Sternoclavicular Joint Xray 1Sternoclavicular Joint Xrays 2






Sternoclavicular Pathology


Condensing Osteitis



- seen in women over 40



- sclerotic and overgrown


Condensing Osteitis Xray




Condensing Osteitis CT 2Condensing Osteitis CT




Sng Ann Acad Med Sing 2004

- follow up of 9 patients mean 34 months

- pain reduced over time





Will resolve with time



- HCLA injection

- excision


Friedrich's Disease


Very rare condition seen in young adults

- AVN of sternal end of clavicle / occasionally lateral end

- pain and swelling

- ESR may be raised

- irregular sclerotic appearance on xray

- rarely requires excision


Sternoclavicular Hyperostosis


Bilateral condition

- ossification of sternoclavicular ligaments

- may lead to solid ossification with restriction of shoulder motion

- associated with pustules and elevated Alk Phos




Sternoclavicular OA






1.  Intra-articular cortisone

2.  Fusion



Suprascapular Nerve



C5, 6 from Upper trunk


Posterior triangle

- arises upper trunk and passes backward through posterior triangle

- under belly of omohyoid

- deep to trapezius to the suprascapular notch


Suprascapular Ganglion Coronal MRI


Runs through suprascapular notch

- under superior transverse scapular ligament

- suprascapular artery and vein run over this ligament

- supplies SS 1 cm after passing under ligament

- give articular branch to the shoulder


Suprascapular Nerve Sagittal MRI 1Suprascapular Nerve Sagittal MRI 2


Passes around lateral border spinous process / Spinoglenoid notch

- under spinoglenoid ligament

- inferior transverse scapular ligament

- supplies IS



-  supplies supraspinatus & infraspinatus




- CA and CH ligaments


Sites of Compression / Injury


Suprascapular notch

- weakness wasting SS & IS



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

- iatrogenic / excessive rotator cuff release

- athletes / repetitive overhead motion


Spinoglenoid notch

- weakness wasting IS



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

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

- posterior shoulder OA causing a cyst




Pain at back of shoulder







Atrophy SS/IS


Atrophy of IS alone




Rotator Cuff tear




1.  Spinoglenoid cyst / labral tear

- may be better seen with MRA


Spinoglenoid cyst Coronal MRISpinoglenoid Cyst Sagittal MRISpinoglenoid Cyst MRI Axial


2.  Atrophy of SS / IS


Spinoglenoid Cyst Infraspinatous Fatty Atrophy


3.  Exclude cuff tear




Demonstrate denervation SS/IS or IS alone




Inject SS nerve at suprascapular notch




Non Operative


Reasonable if no ganglion cyst

- a neuropraxia which usually resolves

- avoid overhead activities if possible

- 6 - 9 months




Spinoglenoid Cyst


1.  Secondary to superior labral tear


Majority of cases


A.  Cyst Decompression + Arthroscopic labral repair



- identify horizontal cleavage tear

- decompress throught tear

- repair labrum


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


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


Piatt et al J Should Elbow Surg 2002

- excellent results


B.  Arthroscopic Labral Repair without cyst decompression


Schroder et al JBJS Am 2008

- 42 patients

- posterior labral repair without cyst decompression

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

- all patients satisfied with outcome


2.  Spinoglenoid Cyst without labral tear


Options to decompress cyst

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

- posterior approach

- arthroscopic glenohumeral approach / posterior capsulotomy

- subacromial approach / between supraspinatous and infraspinatous




Werner et al Arthroscopy 2007

- posterior capsulotomy above IGHL with decompression of cyst with shaver


Posterior Shoulder Capsulotomy to decompress cyst


Ghodadra et al Arthroscopy 2009

- subacromial space

- identify spine of scapula

- dissect between infraspinatous and supraspinatous

- accessory posterior portal, retract IS and nerve

- decompress with shaver


Shoulder Subacromial Space Spinous ProcessSubacromial Spinous Process 1


Suprascapular Notch Impingement


Decompression / Division of Suprascapular ligament 



- weakness atrophy of SS and IS without cuff tear

- massive irreparable cuff tear with intractable pain



- open

- arthroscopic




Lafosse et al Arthroscopy 2007

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

- no complications

- good clinical outcome in all patients


Open Technique

- incision along spine of scapular

- sharply elevate trapezius off spine off scapula

- SS reflected inferiorly to expose notch

- preserve superior NV bundle

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

- divide ligament


Arthroscopic Technique


Standard posterior portal

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

- find coracoid by following CAL to it

- feel hard bony prominence


Anterolateral working portal

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



- clear space medial to coracoid along subscapularis

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

- medial to this is fatty area with THL


SSN Release CoracoidSSN Release Coracoid and CHL


Suprascapular portal / accessory Nevasier

- 7cm from posterior edge of acromion

- insert blunt instruments posteriorly from suprascapular portal

- pass under clavicle

- elevates supraspinous muscle

- use blunt trochar to dissect area



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

- be careful as this runs from subclavian

- can get torrential bleeding


Conoid Ligament  SSA over THLSuprascapular artery and transverse scapula ligament


Identify transverse ligament

- identify SSN passing under

- divide TSL with scissors from posterior ACJ portal

- whilst retracting SS artery with probe from SSN portal


SSN release Divided THLSSN Release Divided TSL

Thoracic Outlet Syndrome



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




80% 30-50 years 


F:M = 2:1 








Thoracic Outlet forms communication at root of neck 

- for passage of nerves and vessels from mediastinum to axilla 

- vein is anterior to Scalenus Anterior




Anterior:  Scalaneus Anterior

Posterior: Scalaneus Medius

Floor:      First Rib

Roof:       Prevertebral fascia & clavicle




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




1.  Cervical Rib

- 5 / 1000 

- only 10% of cervical ribs are symptomatic

- 10% of TOS have cervical rib


Varies from 

- enlarged TP 

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


2.  1st Thoracic Rib

-  abnormal curve 

-  increased size or shape


3.  Clavicle

-  posterior fracture callus 

-  abnormal shape / malunion




Most important cause


1.  Fibrous Band


Cervical rib joined to 1st rib by congenital fibrous band 

-  elevates lower part of brachial plexus 

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

-  9 variants recognised


2.  Scalenus Muscles


Abnormal insertion 

Decreased size of cleft between S Anterior & S Medius





- Precipitates condition in 2/3



- shoulder sags with middle age 

- hyperabduction in sleep

- scapular winging secondary to trapezius palsy



- hyperabduction of shoulders (painters, welders) 

- pressure (backpacks, soldiers)




1. Neurogenic


Compression of brachial plexus alone 

-  usually lower trunk C8,T1

-  most common 95%


2. Vascular


Compression of subclavian blood vessels alone 

- usually vein obstruction 

- occasionally arterial insufficiency 

- rare 2%


3. Combined


Compression of both nerves & vessels 

- rare 3%




2° compression of Plexus > Vessels



-  intermittent

-  suprascapular area and neck

-  may be whole arm

-  more common medial arm & ulnar forearm 

-  radiates to neck 


Worse after activity

- overhead

- carrying heavy weight



- C8 & T1 (mainly ulnar nerve distribution)

- may be whole arm



- most noticeable is grip



- duskiness & cyanosis of hand 



- cold, pale hand & forearm

- Raynaud's 




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


Listen for bruit / compare arm BP



-  decreased in C8 / T1 distribution



-  decreased especially grip strength


1. Elevated Arm Stress Test (EAST)

- shoulder abducted 90° & ER 

- elbows at 90° 

- hands clasped / unclasped for 3min

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


2.  Adson Manoeuvre

- head toward side tested, neck extended

- arm by side

- palpate radial pulse of extended arm

- patient inhales deeply

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


3.  Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm abducted and ER

- breath in

- loss of pulse or reproduction of symptoms

- highly sensitive


Xray neck / CXR


Cervical rib

Clavicle fracture






May show fibrous band 

- exclude cord pathology




Must do with arms abducted and by side

- will show compression of subclavian vein



-  unhelpful as symptoms intermittent 

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

-  exclude CTS / cubital tunnel Syndrome




Cervical Disc (C8/T1) / spinal cord lesion

Ulna nerve entrapment

Shoulder pathology

Pancoast tumour







Explanation & reassurance

- shoulder girdle exercises 

- posture improvement 

- analgesia







10% of patients

- intolerable pain 

- significant loss of function

- significant arterial or venous symptoms




Resection of cervical rib


Resection first rib

Clavicular osteotomy





- pneumothorax 

- empyema 


Nerve injury 

- phrenic nerve 

- T1 


Vessel injury 


Recurrence of symptoms



Throwing Athlete




- cocking

- ER up to 180o in pitcher



- large scapular muscles 

- acceleration - 7000o/sec

- rotatory acceleration similar to car tyre at 130 kph


Control and deceleration

- fragile cuff & glenohumeral ligament complex 




Pitchers have increased ER range, but corresponding decreased IR range

- have increased humeral head retroversion

- probably from adaptations of growth plate whilst young

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


They have a "normal" abnormality


Treatment of posterior capsular stretching in athletes is debatable

- limited IR is normal state


Problems / Spectrum


1.  Subtle anterior instability / Posterior capsular contracture

- internal impingement


2.  SLAP


3.  Posterior instability


4.  RC injuries


Internal Impingement Posterior / Superior Glenoid




Described by Davidson 1997

- throwing athletes

- impingement in ER and abduction

- classic 90 / 90 position

- posterior aspect of SS impinges on posterosuperior rim of glenoid 




Posterosuperior labrum is damaged




Argument whether posterior capsule tightness or anterior instability

- can be either




Usually posterior shoulder pain




Careful comparison of shoulders

- normal to have increased ER / decreased IR



- load and shift examination of instability very important

- need to examine shoulder in 90 / 90 position

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

- this is the throwing position

- look carefully for anterior instability






Bennett's Lesion



- damaged posterosuperior labrum

- partial cuff tears



- place arthroscope anteriorly

- ER arm in 90o abducted position

- see posterior cuff impinge exactly on damaged area of labrum




A.  Posterior capsule tight and thickened

- feel / confirm thickening with probe

- careful release at edge of labrum


B.  Shoulder unstable anteriorly in EUA

- may see anteroinferior labral injury

- may simple be redundant tissue

- anterior labral injury (careful repair with sutures)

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


NB Must be very careful

- cannot afford to lose ER in throwing athlete


Partial Thickness Tears Cuff




Articular sided

- more posterior than in elderly

- at the SS / IS interval

- consistent with internal impingement





Posterior capsular contracture




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


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


Non Operative


1.  ROM / posterior capsular stretches

- decrease inflammation


2.  Balanced RC exercises




Debridement is mainstay

- acromioplasty and repair rarely indicated

- some major league pitchers have full thickness tears

- repair initially may end career


Little Leaguer's Shoulder




Present with painful shoulder




Physeal widening




Chronic SH 1 growth plate









Winged Scapula






Due to scapulothoracic articulation disorder


1.  Neurological Origin


A.  Spinal Accessory Nerve / Trapezius palsy

B.  Long Thoracic Nerve /  Serratus Anterior palsy

C.  Dorsal Scapular Nerve / Rhomboids palsy (rare)


2.  Osseous Origin


Osteochondromas (tangential x-rays, CT useful)

Fracture malunions


3.  Soft Tissue Origin


Muscular Origin

- traumatic ruptures of Serratus Anterior

- iatrogenic during thoracotomy




Due to GHJ articulation disorders

A.  Erb's palsy

B.  Deltoid fibrosis

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






Trapezius Winging / Spinal Accessory Nerve




C3, 4

-  supplies Sternocleidomastoid

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




Stab wounds to neck

Operations on posterior triangle (Lymph node biopsy)

Traction injuries





- will attempt to compensate by using levator scapulae

- can lead to disabling pain and spasm

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




Shoulder depressed

- scapula translated lateral 

- inferior angles rotated laterally


Trapezius wasting

- unable to shrug shoulders

- weakness with protraction


Non operative management


Reasonable for a time for traction injury

- physio

- wait 6 - 12 weeks




1.  Neurorrhaphy

- direct repair for open laceration


2.  Nerve Graft


3.  Levator scapulae and Rhomboid transfer

- Eden-Lange procedure

- most common



- L. Scapulae to medial acromion

- R. minor upper 1/3

- R. major middle 1/3


4.  Scapulothoracic Fusion

- reasonable pain relief

- poor function

- high complication rate


Serratus Anterior winging / Long Thoracic Nerve




C 5, 6, 7 from Roots

- runs down posterior axillary wall

- deep to fascia

- posterior to midaxillary line

- supplies Serratus Anterior



- boxer's muscle

- protracts scapula



- fleshy slips

- upper 8 or 9 ribs



- costal aspect medial margin





- shoulder or neck operations

- 1st rib resection

- mastectomy


Carrying loads on shoulder




Repetitive microtrauma - swimming




Winging of scapula

- scapula medial




1.  Nerve Transfer 

- TDN to LTN


2.  Stabilisation of scapula / Marmor-Bechtol transfer

- transferring sternocostal head Pectoralis major to inferior corner scapula

- require fascia lata extension







EpidemiologyShoulder OA


Usually 50-60 years old




1° uncommon


2° most common


- trauma

- cuff arthropathy (Neer)

- instability




Cuff & biceps intact as rule

- rare to have OA and rotator cuff pathology


Inferior osteophytes 

- beard


Retroversion of glenoid 

- posterior wear


Posterior subluxation not uncommon


Shoulder OA Posterior Subluxation


Tight anterior capsule & subscapularis

- limitation of ER


Post traumatic

- always soft tissue contracture

- limitation of ER

- CH ligament and rotator interval contracted

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

- non-union results in extensive shortening of cuff

- scarring about axillary nerve


Shoulder OA post trauma




Global painful restriction of range of movement 

- due to incongruity of joint surfaces

- crepitus

- limitation of ER


DDx Limitation ER


Frozen Shoulder

Chronic posterior dislocation

Arthrodesis = Lack of ER

Post septic arthritis




Shoulder OAShoulder OA Xray


Typical changes of OA

1. Teardrop osteophytes on inferior head & glenoid

2. Osteochondral loose bodies


Shoulder Loose Body



- cuff arthopathy - proximal migration of head & subacromial sclerosis




Shoulder OA GlenoidShoulder OA Debridement






Education & Reassurance

- Analgesia


- Physio






1.  Arthroscopic Debridement



- if patient has acromial spur and acromioclavicular pathology

- may benefit from debridement

- concept of limited goals




A.  Glenohumeral joint

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

- synovectomy


Shoulder OA Synovitis


B.  Subacromial space

- acromioplasty

- CA ligament left intact

- ACJ resection


C.  Removal beard osteophyte

- additional option

- may improve ROM

- risk of axillary nerve injury


2.  Arthrodesis



- may be considered in young active patient



- good pain relief but limitation movement

- difficult to perform

- rarely done in the modern age


3.  Excision Arthroplasty



- good pain relief but main problem is flail arm


4.  Arthroplasty



- hemiarthroplasty (young patient or insufficient glenoid bone stock)



Pectoralis Major Tears



Middle age men

Steroids / Growth Hormone




Usually occurs in gym

Bench Press




Significant bruising in the acute phase


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


Pectoralis Major TearPectoralis Tear 2


Usually complain of weakness, mainly in gym




MRI Pectoralis Major TearPectoralis Tear MRI


Chronic Pectoralis Major 1


Pectoralis Major 3Pectoralis 3




Non operative


Good results

Will have cosmetic deformity

Weakness usually only in the gym with bench press





- acute tears in young patients

- cosmesis i.e. body builders


Acute repair


Pect Major Repair Through Bone TroughIncision Pec Major Repair



- deltopectoral approach / can alos make in skin crease

- find tendons medially

- drill one inche trough in humerus

- place sutures in tendon

- pass sutures through drill holes lateral to trough

- pull tendon into trough and tie sutures


Chronic Reconstruction



- tendoachilles graft

- pass through muscle in pul ve taft method

- tie down into bone trough in humerus


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

Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture


Third most common fracture after hip and distal radius




FOOSH - mostly elderly patients with osteoporotic


Young patients - high energy MVA




Neck shaft angle 130o

Head retroverted 20o relative to shaft

Anatomical neck (junction of head and metaphysis)

Surgical neck (junction of diaphysis and metaphysis)


Neer Classification 1970




Any fragment

- > 1cm displaced

- > 45o angulated


Number of displaced fragments


Two part (head/shaft, GT, LT)

Three part (head/shaft/GT, head/shaft/LT)

Four part (head/shaft/GT/LT)


Two part fractures


Surgical neck of humerus


Pectoralis major displaces shaft medially

Head internally rotated by subscapularis


SNOH Fracture DisplacedTwo part SNOH


Greater tuberosity fracture


Fragment pulled postero-superior by supraspinatus and infraspinatus


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


Lesser tuberosity fracture


Displaced medially by subscapularis


Lesser Tuberosity FractureLesser Tuberosity Fracture 2


Three and four part fractures

Fracture / dislocations


Humerus Anatomical Neck FractureProximal Humerus Fracture DislocationShoulder Fracture Dislocation Anterior


Posterior Shoulder Fracture DislocationShoulder Fracture Dislocation


Head splitting fractures


SNOH Head Split CTProximal Humerus Head Split CT


Blood supply


1.  Anterior humeral circumflex


Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis


Nearly always disrupted in fractures


2.  Posterior Humeral circumflex


Small contribution posterior head

- allows head to survive with both tuberosities fractured


3.  Rotator cuff


Supplies blood to tuberosities in fractures


Avascular necrosis




Risk AVN


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

- posterior circumflex artery is sufficient

- risk increases with amount of displacement


Four part fracture 30%


Three part fracture 15%


Hertel Radiographic criteria


Hertel et al J Should Elbow Surg 2004



2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm


97% positive predictive of ischaemia if both factors present

Associated Injuries


Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid


Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand


Clinical scenarios


1.  Displaced fractures in the elderly

2.  Displaced greater tuberosity fractures

3.  Displaced lesser tuberosity fractures

4.  Displaced fractures in young patients


Displaced fractures in the elderly




High risk of fixation failure due to poor bone stock






Reverse Total Shoulder Replacement




Nonoperative v surgery


Rangan et al. JAMA 2015

- RCT of 250 patients

- mean age 66 (range, 24 - 92)

- sling v ORIF / humeral head replacement

- no difference in patient reported outcomes at two years



Navarro et al. PLoS One 2018

- systematic review of op v nonop in the elderly

- 4 RCTs (373 patients) comparing various operative interventions and sling

- 2 RCTs comparing hemiarthroplasty and sling

- no difference in functional outcome at one year



Iyengar et al. J Orthop Trauma 2011

- systematic review of nonoperative treatment

- 650 patients

- average 140o forward flexion

- union rate 98%



Hemiarthroplasty v Reverse TSR


Shukla et al. J Shoulder Elbow Surg 2016

- meta-analysis of one level I, one level II, and three level III studies

- better ROM and functional outcomes with reverse TSR



Sebastia-Forcada et al. J Should Elbow Surg 2014

- RCT of 62 patients > 70 years old

- better forward flexion with reverse TSR (120o v 80o)

- better abduction with reverse TSR (113o v 79o)

- better pain and function with reverse TSR



Jonnson et al. J Should Elbow Surg 2021

- RCT 84 patients > 70 years old

- better Constant score with reverse TSR (59 v 58)

- better forward flexion with reverse TSR (125o v 90o)

- better abduction with reverse TSR (112o v 83o)

- less difference with patients > 80 years old



Reverse TSR v plate fixation for elderly


Fraser et al. JBJS Am 2020

- RCT of 124 patients

- superior outcomes for reverse TSR



Indications for surgery in the elderly


Fracture dislocation

100% displacement - high risk of nonunion


Complications of nonoperative treatment




Proximal humerus non union 1Proximal humerus nonunion 2





Reverse TSR

Fibular strut allograft + ORIF


Fibular strut allograft nonunion 1Fibular strut allograft 2


Malunion / dysfunction / osteoarthritis


SNOH MalunionSNOH Malunion



- anatomic TSR

- reverse TSR

- consider osteotomy in young patients


Raiss et al. JBJS Am 2016

- reverse TRS for 42 patients with fracture malunions

- significant improvements in pain and ROM

- 98% good or satisfactory outcomes

- one patient had loosening of components



Displaced fractures of the greater tuberosity




> 5 mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step


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




Suture and repair over distal screw

Hook plate

Lateral plate






Deltoid splitting approach

Axillary nerve 4 - 5 cm below acromion


Young patient can ORIF with screw



A. Insert Mason Allen no 2 suture in cuff and tie over distal screw

B. Synthes 3.5 mm LCP hook plate


 ORIF Greater Tuberosity FractureGreater tuberosity Tie over screw


3.5 mm LCP Hook Plate


Displaced lesser tuberosity fractures






Can be sustained in adolescent patients

- injury is missed until the lesser tuberosity ossifies


Can be associated with posterior shoulder dislocation




Deltopectoral approach

- identify lesser tuberosity

- medial to long head of bicpes



- fix with screws

- can perform double row repair


Lesser tuberosity fractureLesser tuberosity fractureLesser tubersity fractureLesser tuberosity ORIFLesser tuberosity ORIF

Lesser tuberosity fracture following posterior shoulder dislocation


LT displacedLT displaced


Chronic lesser tuberosity avulsionChronic lesser tuberosity ORIFLT ORIF

Missed chronic lesser tuberosity avulsion in adolescent, repaired with medial row suture anchors and lateral screws



ORIF with soft tissue washer


Displaced Proximal Humerus fractures in Young Patients


Indications for ORIF


Young patients

>1 cm displaced or > 45o angulation

Sufficient bone for fixation


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





- number of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF?


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


ORIF with plate technique


SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CTProximal humerus ORIF 1Proximal humerus ORIF 2


Plate options


A.  Lateral




Snythes Philos plate



B.  Anterolateral


SNOH Periarticular plate 1SNOH Periarticular plate 2


Newer plates sit slightly anterior to minimise deltoid retraction

Have posterior sweep of buttress that sits on greater tuberosity


Synthes Peri-articular proximal humerus plates





Vumedi video



Vumedi video



Set up

- GA, IV antibiotics, lazy beach chair

- bolster under shoulder to ensure adequate good AP images

- mark anatomy

- ensure adequate flouroscopy images


A. Deltopectoral approach 

- cephalic usually taken laterally

- Hawkins Bell retractor/ blunt gelpies

- divide clavipectoral fascia to expose subscapularis

- release lateral edge of conjoint tendon

- place retractors deep to tendon

- release adhesions from undersurface of deltoid


Extensile approach

- release CA ligament

- release proximal pectoralis major

- can release anterior deltoid insertion from clavicle if needed (intra-osseous repair later)



- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially


B.  Anterolateral deltoid split

- identify axillary nerve

- slide plate under nerve


Identify structures

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

- remove hematoma

- open rotator interval to glenoid


Reduce head onto shaft using elevator

- head is displaced posteriorly and into varus

- can use lamina spreader to keep head out of varus

- consider medial allograft strut

- provisionally fix with 2 mm k wires

- check provisonal fixation with fluoroscopy

- ensure head out of valgus / restore medial shentons line

- abduction of the arm can help




Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check fluoroscopy to avoid having plate too high

- keep head out of varus to avoid cutout

- long inferomedial screws / kickstand screws

- must ensure that screws are not in joint





- pass sutures through holes in plate




Head collapse and screw cutout


Medial support very important

Must avoid varus malreduction


Plate impingement


Need to ensure place plate low on the head


Screw perforation of humeral head




Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral




Vascular Injury


Axillary / MCN / Brachial Plexus


Hemiarthroplasty for displaced fractures in the elderly




Unreconstructable with displaced tuberosity fragments

Fracture dislocations

100% displaced / high likelihood of nonunion


Proximal Humerus 4 Part Fracture In ElderlyComplex proximal humerusDisplaced SNOH





Reverse total shoulder replacement




SNOH Hemi 2SNOH Hemi 1




ROM often poor

- rarely > 90o

- ust ensure tuberosities heal or outcome will be worse


Failed hemiarthroplasty




JP Warner Vumedi video



Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair


Deltopectoral approach

- identify biceps tendon

- allows identification of LT medially and GT laterally

- release biceps tendon


Remove and tag tuberosities

- two Mason Allen sutures in each

- often useful to debulk tuberosities


Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation


Ream humerus and trial stem

- use a trauma stem as will have holes for tuberosity fixation

- retroversion of 20 - 30o

- typically there is a fin to position with the forearm when flexed

- important to assess height

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities


Cement stem with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture

- place on head with 12/14 taper


Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole


Biceps tenodesis




Tuberosity nonunion


Late glenoid wear and pain


Reverse total shoulder for displaced fractures in the elderly


Reverse TSR fractureTrauma Reverse TSR






Improved outcomes with reattachment


Jain et al. J Should Elbow Surg 2019

- systematic review of 382 reverse TRS for fracture

- improved ROM and outcome scores with healed tuberosities






Deltoid split




Fracture specific reverse stem

Allows reattachment of the tuberosities




Vumedi Video



Surgical techique PDF




- assess metaphyseal bone loss

- assess glenoid characteristics



- deltopectoral

- anterosuperior / deltoid split


Set up

- beach chair

- arm able to be fully extended



- identify and release biceps tendon

- open rotator interval

- identify and tag tuberositys with high strength sutures

- remove humeral head


Expose and prepare glenoid

- anterior, posterior and inferior retractors

- remove labrum

- identify coracoid

- mark the vertical and horizontal parameters of the glenoid

- superior screw will go into base of coracoid

- place metaglene drill guide flush inferiorly

- must not tilt inferiorly to avoid scapula notching

- secure with K wire, ream to remove cartilage

- implant metaglene / base plate and fix with screws

- consider using lateralised glenosphere


Prepare and insert humeral stem

- ensure correct height (use tuberosities, or 5 cm above pect major)

- 20o retroversion

- trial

- cement in prosthesis

- trial again with poly


Repair tuberosities to the fracture stem





Rheumatoid Arthritis

EpidemiologyRheumatoid Shoulder




2/3 involved

- ACJ arthritis

- subacromial bursitis / rotator cuff pathology

- GHJ less commonly




1.  ACJ 

- erosive arthritis

- joint expands with severe involvement

- ACJ capsular destruction / instability / impingement


2.  Subacromial Bursa

- becomes inflamed & thickened

- rupture of LH of biceps / cuff rupture

- rotator cuff arthropathy


3.  GHJ

- develop marked soft tissue inflammation

- 2° laxity capsule & folds of synovium

- followed by severe cartilage & bone erosion


Neer described 3 types RA shoulder

- Wet = Synovitic with soft tissue pathology

- Dry = Articular Surface Erosion

- Resorptive = Severe Bony Erosion




Shoulder pain & swelling with flares of RA

- gradually decreasing ROM

- functional impairment


Cuff Tendonosis 

- pain with overhead activity





- muscle wasting

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

- effusion with swelling


Cuff rupture 

- loss of abduction


Biceps rupture / popeye


Painful arc




Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions


Rheumatoid Shoulder Erosions


Symmetric Arthritis



- medialisation of humeral head

- can erode anteriorly or posterior

- inferior glenoid preserved


Rheumatoid Shoulder 2


Superior migration due to cuff rupture


Arthritis mutilans


Arthritis Mutilans RA


US / MRI / Arthrogram


30% have cuff tear


Rheumatoid Shoulder Arthrogram Cuff Tear




Assess glenoid stock


Rheumatoid Shoulder CT





- 20 000 WBC / ml

- 60-70% neutrophils



- > 100 000 WBC / ml

- > 75% neutrophils




Septic arthritis



- sodium urate



- calcium pyrophosphate


Milwaukee Shoulder

- calcium hydroxyapatite crystals


RC arthropathy


OA - beard osteophytes





- Medical treatment

- HCLA injections




Excision of outer 1/3 of clavicle


Subacromial Bursa







1.  Arthroscopic Synovectomy 



- mild arthritis / cuff intact



- synovectomy

- via anterior and posterior portals

- removal loose bodies

- biceps tenotomy

- bursectomy / ACJ resection if necessary

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


Rheumatoid Shoulder Arthroscopy Rheumatoid Shoulder Post Debridement


Rheumatoid Shoulder Arthroscopy 2Rheumatoid Shoulder Arthroscopy 3


Cofield et al Arthroscopy 2006

- 16 shoulders followed up for 5 years

- 13/16 good pain relief

- some mild improvement in ROM

- arthritis tended to progress over time


2.  Hemiarthroplasty / TSR


Indications hemiarthroplasty

- young patient

- glenoid not involved / unusual


Indications TSR

- sufficient bone stock glenoid

- glenoid often deficient centrally and superior

- intact RC

Cofield et al J Should Elbow Surg 2001

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

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


4.  Reverse TSR



- ruptured cuff (30%)


Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

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

- 5 patients required bone grafting of glenoid defects


5.  Arthrodesis

- indicated for severe bone loss

- problem is actual or potential involvement of other joints


6.  Excision arthroplasty

- salvage procedure

Rotator Cuff

Calcific Tendonitis



Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia


Supraspinatous CalciumSupaspinatous Large Deposits




2 groups of patients


1.  Degenerate Calcification


Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller


These patients do not have calcific tendonitis

- older patient group

- different histology


2.  Calcific Tendonitis




Reactive Hypoxic Calcification Theory


Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium


Codman proposed cuff hypoxia as the causative factor




1.  Pre-Calcific stage


Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia


2. Calcific Stage


A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

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


B. Resting Stage

- fibrocartilage surrounds deposits


C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma


3. Post-Calcific Stage


Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I




Accounts for 10% all consultations for painful shoulder


Peak 40 years

- diabetes

- F > M 


SS most common tendon

- IS less common

- SSC rare


Asymptomatic patients can have cuff calcium on xray


Clinical Presentation


Usually acute pain

- Resorption Stage

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


Patients may present to ED

- severe pain


DDx infection




Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD





Calcific Tendonitis APCalcific Tendonits Lateral


Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size


ER AP Xray

- shows SSC


Subscapularis CalciumSubscapularis Calcium Lateral


IR AP Xray

- shows IS & Tm


Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak


Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density




Low signal on T1 

Oedema on T2


Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2



- more sensitive than Xray ~100%


Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous




Check serum glucose / uric acid & iron




Non operative Management





- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration


Extracorporeal shock wave therapy


Extracorporeal Shock Wave Machine


Peters Skeletal Radiol 2004


- 90 patients

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

- control group 0 disappeared completely, 9% partial reduction

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

- no adverse affects


Effectiveness directly related to energy

- 0.44 mJ/mm3


Needle aspiration and irrigation



- drain a substantial portion of the calcium

- stimulate resorption of remainder



- resorption phase (soft, toothpaste material)



- small deposits

- formative phase (hard, chalky material)



- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive



- very painful for first 2-3 days




Aina et al Radiology 2001

- excellent results in 74%


Serafini et al Radiology 2009

- non randomised controlled trial

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

- no difference long term


Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone


Operative Management



- severe disabling symptoms > 6 months

- failure of needling / ECSW





- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement


Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

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





Arthroscopic and mini open



Arthroscopic Technique


Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit


Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon


Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness


May need to remove entire diseased section and repair


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




Secondary stiffness



- secondary to calcium deposits

- careful shoulder washout at the end of the case



Cuff Tear Arthropathy



Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch





- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases




Crystal induced arthropathy

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

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally


Cuff tear theory

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

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




4% of massive cuff tears go on to arthroplasty



- tears with unbalanced force couplet go on to arthropathy 

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




Women > men

60% bilateral




Recurrent swelling

Loss of Motion

Night pain




1.  Superior migration of head 

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


Humeral Head Superior Migration


2.  Collapse of proximal head articular surface 


3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity


4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification


Acromial Acetabularisation




RC Arthropathy CT





- no superior migration

- beard osteophytes






Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia


Operative Management


1.  Acromioplasty & tendon debridement 


Not indicated with superior migration

- can consider biceps tenotomy if still intact


2.  Arthrodesis


Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid


3.  TSR 


Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 


4.  Hemiarthroplasty



- < 70

- intact CA arch

- anterior deltoid muscle



- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape





- 18 of 21 satisfactory

- good pain relief

- ROM often not improved



- concept of limited goals category

- 20° of ER and 90° of forward elevation


Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency


5.  CTA Humeral Head


Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER


CTA HemiarthroplastyCTA Head APCTA Head 2


6.  Reverse TSR



- > 70

- functioning deltoid



- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder





Arthroscopic Acromioplasty




- beach chair / lateral

- water pump, adrenaline in bags

- block pre-op useful as easier to control BP

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


Posterior portal

- 2 cm inferior, 1 cm medial

- soft spot between IS and Tm


Enter subacromial space

- sweep to clear adhesion

- saline on pump at 30 - 40 - 50

- keep BP  100 - 110

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


Midlateral portal

- spinal needle

- 3cm distal to anterior acromion

- midpoint clavicle

- slightly lower to aim up



- with shaver


Arthroscopic Bursectomy


Electrocautery / Shaver

- clear periosteum / coracoacomial Ligament off acromion

- avoid deltoid as bleeders

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

- spinal needle ACJ to mark medial limits

- need to see anterior and lateral acromion


Arthroscopy Type 3 AcromionShoulder Scope Large Acromial Spur



- 5.5mm burr

- multiple techiques

- 5mm deep resection at midpoint clavicle

- taper anteriorly

- must ensure lateral edge is cleared


Arthroscopy Post AcromioplastyArthroscopy Cleared Subacromial Space


Residual Lateral Acromial Spur






DefinitionLateral Acromial Spur


Painful impingement of rotator cuff

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

- causes tendinosis of the RC


Anatomy Subacromial Space


1.  Roof / CA Arch

- acromion

- CA ligament

- coracoid process

- ACJ is superior & posterior to CA ligament


2.  Floor 

- GT & superior aspect head

- rotator cuff





- extrinsic and intrinsic theories


1.  Extrinsic / Extra-tendinous / Bursal sided tears


CA arch impinges on RC

- true impingement syndrome

- causes tendinosis of the cuff




A.  Subtle GH Instability

- relationship poorly understood

- respond poorly to acromioplasty

- alteration in dynamics of shoulder


B.  Internal Impingement Posterior / Superior Glenoid


Described by Davidson 1997

- throwing athletes

- impinge in abduction & ER

- SS impinges on posterosuperior rim of glenoid 

- normally humeral head translates posterior in glenoid 

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

- alternatively may be caused by posterior capsular tightness


See Miscellaneous/Throwing Athlete


C. Degeneration ACJ


OA Spurs


D.  Acromion Morphology


Neer = impingement on anteroinferior acromion 


E.  Os Acromiale

- mesoacromion most common

- hypermobile unfused epiphysis

- tilts anteriorly

- 1-15% normal population

- increased incidence with impingement


F.  CA Ligament Spurs 


Develop calcium in tendon


G.  CA Ligament Impingement

- common

- "Snapping shoulder"

- in flexion & IR

- SS & Biceps impinge on it

- Neer recommends division


H.  Coracoid Impingement

- less common

- subscapularis impingement between coracoid and LT

- may be exacerbated by anterior instability

- more medial pain with arm flexed, adducted and IR

- find SSC partial tears on arthroscopy


Coracoid Impingement Lateral Coracoid


2.  Intrinsic / Intra-tendinous / Articular sided tears


2° to bursal thickening or intrinsic problem in cuff

- ? Now thought to be most common




1. Muscle Fatigue

- overloaded weak muscles

- eccentric tension load

- associated with proximal humeral migration


2. Shoulder Overuse

- soft tissue inflammation

- repetitive microtrauma

- athletes / manual labourers


3. Degenerative Tendinopathy

- 1° intrinsic degeneration of RC

- ? hypovascularity

- increasing incidence with age




Impingement Zone 

- centered on supraspinatus tendon insertion

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

- zone of hypoperfusion


Neer's Pathological Classification


Stage I

- reversible

- oedema & haemorrhage

- < 25 years


Stage II

- irreversible change

- fibrosis & tendinitis

- 25-40 years


Subdivided by Gartsman

- Stage IIA = No tear

- Stage IIB = Partial thickness tears


Stage III

- > 40 years

- chronic

- partial & full thickness tears


Acromial Morphology


Bigliani / Assess on Supraspinatous Outlet View / Scapula Lateral


Type I:  Flat

- 20% of normal population


Type 1 AcromionType 1 Acromion


Type II:  Curved

- 40% of normal population


Type 2 Acromion


Type III:  Hooked

- 40% of normal population

- 80% of RC tears


Type 3 AcromionAcromion Type 3Acromial Spur Type 3


Cadaver study

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

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


Morphology does change with age

- Spur more common > 50 years

- ? 2° event to cuff process

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




Painful arc


Weakness overhead


If < 40 years look for instability




Painful Arc

- 70-120°

- > 120° - ACJ OA / terminal phase pain



- limitation of IR may suggest posterior capsular tightness


Neer Impingement Sign

- stabilize scapula from behind patient

- passively elevate arm in scapula plane

- pain between 70-120°


Hawkins Modification

- IR humerus at 90° flex


Neer Impingement Test 

- LA in SAD

- abolish pain & test for cuff tear / weakness



- anterior apprehension / Jobes relocation (young patient)

- ACJ assessment

- biceps assessment


- C spine




AP view (True AP)

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

- sclerosis greater tuberosity / acromion

- lateral Acromion spur



Acromial Spur AP


Axillary Lateral

- os acromion

- bone scan to exclude symptomatic hypermobility


Os Acomionale Axillary Lateral Xray


Supraspinatus Outlet View

- Acromion morphology / calcification Coraco-Acromial Ligament

- scapula lateral variant

- plate on affected shoulder, other turned out of way 

- 10° caudal


Scapular Lateral for Acromial Morphology


Zanca view


- half voltage / centred on ACJ / 10o cephalad





- dynamic impingement

- bursitis


Shoulder Ultrasound Bursitis





- assess acromial morphology

- look for tendinosis / tears


MRI Type 3 Acromion




Non Operative


HCLA injection 



- decreases pain & inflammation

- diagnostic


Alvarez et al Am J Sports Med 2005

- RCT HCLA v LA in RC tendonosis

- no clinical difference between the two groups


Cuff Rehabilitation


Rockwood 3 Stages of Physio


1. Decrease Inflammation / Increase ROM

- rest

- gentle ROM 

- posterior capsular stretches

- scapula & trunk stabilisers

- modify activities



2. Cuff Stabilisation and Balancing

- strengthen humeral depressors

- work on SSC and IS

- takes load off SS

- theraband / IR / ER exercises

- avoid abduction drills


3. Deltoid strengthening

- task specific exercises


Operative Management






Believe primary problem is extrinsic impingement

- abnormal acromial morphology on outlet view

- spurs in CA ligament




Ketola et al JBJS Br 2009

- RCT of patients with impingement

- treated with exercise program or acromioplasty + exercise program

- no difference between the two groups


Henkus et al JBJS Br 2009

- RCT of bursectomy alone v bursectomy + acromioplasty

- no difference between the two groups


Open v Arthroscopic Acromioplasty




Sachhs JBJS 1997

- open v arthroscopic

- open longer return to work & in hospital stay

- results similar


Davis et al Am J Sports Med 2010

- meta-analysis of open v arthroscopic acromioplasty

- no significant difference in outcome

- longer return to work and inpatient stays

Open Acromioplasty

Described by Neer / modified by Rockwood


Two Step Acromioplasty


1.  Anterior acromioplasty

- resect anterior acromion back to ACJ

- prevent impingement in flexion


2.  Resect anteroinferior acromion 





- beach chair 

- mark anatomy

- limb draped free



- along anterolateral border acromion

- curve into anterolateral incision


Superficial Dissection 

- expose deltoid to ACJ

- find fibrous raphe at anterolateral corner acromion 

- marks anterior & middle parts of deltoid

- split raphe 3cm, ensure protect underlying cuff

- bursa is now exposed, separate subdeltoid space


Deep Dissection

- detach deltoid from anterior acromion to ACJ 

- release CA ligament 

- place retractor under acromion to protect cuff

- tablespoon, Langerhan's retractor turned on side


2 stage acromion resection with microsagittal saw

- anterior acromion level with ACJ

- antero-inferior acromion

- ensure surface smooth


Resect distal 2cm clavicle if OA

- < 4% of patients

- only if pain referable to ACJ 

- confirmed by LA preoperatively



- inspect cuff & repair defects

- abduct & rotate humerus

- biceps tenodesis if > 50% torn



- ? repair CA ligament

- reattach Deltoid No. 2 ethibond intraosseous sutures


Post Op

- rendulum exercises & passive flex

- sling for comfort

- no active abduction for 6/52 to protect deltoid




RC Tears

Arthoscopic Supraspinatous Repair


Large Supraspinatous TearSS tear arthroscopy GHJSS tear arthroscopy




Improved cosmesis

Shorter hospital stay / less immediate post operative pain

Deltoid not detached

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




No quicker to rehab or return to activities 

- limiting factor is healing of tendon to bone

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

- steep learning curve / longer surgery




1.  Footprint

- 25 x 15 mm

- healing zone

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


2.  Suture technique


Note:  Most common means of failure is suture cutout


A.  Open transosseous



- performed in open surgery

- captures a wide section of cuff footpring

- very secure repair with uniform compression between cuff and bone


B.  Single row repair



- anchors placed in line laterally at insertion


C.  Double row repair



- medial anchor row at articular margin

- lateral anchor row at lateral footprint


Kim et al Am J Sports Med 2006

- biomechanical study

- more successful at restoring footprint

- less gap formation

- increased load to failure


D.  Transosseous equivalent / suture bridge



- biomechanically replicate tradional open transosseous

- sutures crossed as below in double row

- aiming to increase contact between cuff and footprint


Arthroscopic Suture Bridge Cuff Repair


Siskoksy et al AAOS 2007

- biomechanical study suture bridge v double row

- bridge higher load to failure

- no difference in gap formation




Outcome arthroscopic


Lafosse et al AA Should Elbow Surgeons 2006

- 105 patients treated with double row

- 11.45 structural failure on CT / MRI


Sugaya et al JBJS Am 2007

- prospective study 106 FT

- arthroscopic double row

- MRI follow up

- 17% retear

- 5 % small to medium

- 40% large and massive


Arthrocopy v mini-open


Kim et al Arthroscopy 2003

- arthroscopy v mini open

- similar outcomes in each group

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


Verma et al Arthroscopy 2006

- arthroscopy v mini open

- US review

- 24% retear mini-open

- 25% retear arthroscopic

- no difference in outcome


Bishop et al AAOS 2004

- mini open v arthroscopic

- MRI review

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

- tears > 3m: 38% v 76%

- do larger tears do better with open surgery?


Morse et al Am J Sports Med 2008

- meta-analysis of arthroscopic v open

- no difference in outcome or complications


Single v Double Row


Francheschi et al Am J Sports Med 2007

- RCT single v double row

- 60 patient

- no difference functional outcome

- improved cuff appearance on MRI


Burks et al Am J Sports Med 2009

- RCT single row v double row

- 20 in each group

- 1 retear in each group

- no difference in MRI appearance or clinical outcome




Churchill et al J Should Elbow Surg

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

- even at high volume centres


Arthroscopic Supraspinatous Repair





- lateral decubitus with arm traction 10 lb or

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

- water pump

- useful to have adrenalin in bags

- stable BP 110 (interscalene block can help)

- inject LA with A into subacromial space and prospective portals




Posterior Portal

- make more superior and lateral

- awkward for GHJ arthroscopy

- good visualisation in subacromial space

- will put camera over and high above tear


Lateral portal

- standard position

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

- perform bursectomy +++ for visulisation

- bursa posteriorly and medially often bleeds

- perform SAD

- control bleeding with electrocautery and temporary increases in pump pressure


Anterior portal

- smaller 6 mm

- for suture shuttling




Prepare insertion

- debride tendon edges

- debride footprint to punctate bleeding


Arthroscopic Cuff TearArthroscopic Cuff Prepare InsertionArthroscopic Cuff Prepared Footprint


Assess tendon mobilisation / tear geometry

- perform releases if needed

- as per open surgery

- above and below tendon 1 cm medial to glenoid

- release coracohumeral ligament




Large U shaped tendon

- insert margin convergence sutures

- put camera in lateral portal

- insert posterior cannula over switching stick

- anterior and posterior bird beaks


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


Place medial row anchors

- anterior first

- insert 18 G spinal needle and ensure good angle

- just medial to articular cartilage

- stab incision

- insert 5 mm anchor


RCR arthroscopic Spinal NeedleRCR Arthroscopic TapRCR Arthroscopic AnchorRCR Arthroscopic Anchor 2


Pass sutures in lateral margin cuff

- camera posterior

- elite / scorpion / concept suture passer via lateral portal

- pass sutures through cuff anterior to posterior

- retrieve sutures through anterior portal

- retrieve via anterior portal


Suture PassageSuture Retrieval


Repeat with posterior anchors


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


Tie sutures

- posterior to anterior / anterior to posterior


Double row

- either pass second lateral row of anchors or

- use foot print anchors, retrieve previous sutures

- can make suture bridge configuration

- check repair via lateral portal


Arthroscopic Supraspinatous RepairArthroscopic Cuff Suture Bridge RepairArthrscopic Cuff Repair






Full thickness tear (FTT)

- variable amount retraction from insertion


Rotator Cuff Tear Large


Partial thickness tear (PTT)

- incomplete

- bursal or articular sided


Articular sided tearBursal Tear




Older patients

- average age 60

- uncommon < 40

- cadavers  30%


Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years




Blood Supply


Proximal from muscle belly

- suprascapular artery

- subscapular artery


Distal from bone

- branch of anterior circumflex humeral


Vessels more abundant on bursal side than articular side




1.  Healing

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


2.  Progression

- tears do not necessarily extend


3.  OA

- 5% FTT go on to cuff arthropathy if untreated




Chronic Tears

- 95% 

- abnormal tendon


Acute tears

- trauma 

- 5% 

- normal tendon




No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia



- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn




1.  Size 



- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm


2.  Extent


Partial Thickness


Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium


A.  Intra-tendinous

- in tendon

- no communication with bursa / joint


Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis


B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly


Supraspinatous articular sided tear


C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement


Full Thickness


One tendon 

- supraspinatus only


Multiple Tendons 

- more likely OA if multiple tendons involved


3.  Topography


Sagittal Plane


Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons


Coronal Plane


A. Minimal retraction

- close to insertion


Supraspinatous Tear Minimal Retraction


B. Moderate retraction

- humeral head


Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2


C.  Significant retraction

- at glenoid


Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1







- 2° to tear

- can be limited by pain

- can use LA to differentiate


History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon


Chronic Tear 95%

-  long history impingement

-  no history of injury




SS IS Clinical Photo 1SS IS Clinical Photo 2



- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears


Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear




1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate


2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o


3.  Shoulder hiking

- usually means massive cuff tear


Shoulder Hiking




1.  Resisted ER


2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags


3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor


Involvement of IS can often indicate a large or massive tear




1.  Gerber lift-off test

- IR hand to back pocket

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

- need sufficient IR for this test

- otherwise need belly press test


2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly


3. Increased ER compared with other arm


Subscapularis tear increased ER




Improves pain and allows physio



- ensures pain from shoulder pathology




Views as for impingement

- assess acromion / GHJ OA / high riding head





- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery



- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

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




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

- MRA most accurate

- MRI and US comparable




Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal




Shoulder Ultrasound Supraspinatous Tear




Arthrogram Intact RC




Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 


Shoulder MRI Supraspinatous Fatty Infiltration


Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space


For more MRI see

- massive tears

- partial thickness tears

- full thickness tear




Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space


Management Guidelines


1. Repair all acute full thickness tears


2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain


3. Observe chronic tears with no disability

- especially in elderly


Non-operative Management


As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears




Full Thickness Tears

Surgical Options


1.  Open antero-lateral approach 


Large / Massive Cuff Tear


2.  Deltopectoral approach


Large Subscapularis tear


3.  Arthroscopic Assisted Mini-open



- Small / Moderate Cuff Tear < 3cm

- no retraction



- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split



- avoids deltoid detachment from acromion

- small scar

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


4.  Arthroscopic repair




Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not


Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs


Biceps / SLAP


Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group




4 types of cuff tears


1.  Cresent shaped

- simple lateral repair


Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped


2.  U shaped

- larger

- need margin convergence, then lateral repair


Supraspinatous Tear U shaped


3.  L shaped


Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly


4.  Massive


Rotator cuff retracted to glenoid


1.  Open Rotator Cuff Repair



- large to massive tear



- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures



- reliable

- good results in terms of tendon healing and outcome



- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

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

- ? management of biceps





- lazy beachchair



- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid



- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

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

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery



- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure




Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint


Techiques to mobiise retracted SS tendon


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

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

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

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

6.  Medialise insertion - take away some of articular cartilage

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


Repair Options


1.  Direct suture of tendon

- margin convergence


2.  Suture of tendon to bone


A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across


Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral


B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors


C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)


3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head


Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow



- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery


Large - Massive Tear 


Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above


Post op


Must protect deltoid repair

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

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12


Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM


2.  Arthroscopic SAD + Mini open Rotator Cuff Repair



- perform subacromial decompression with arthroscope

- no need to detach deltoid

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



- moderate size tear up to 3 cm



- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above




Open v Mini-open


Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years


Tear integrity


Papadopolous et al J Should Elbow Surg 2011

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

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

- most patients had satisfactory outcome





- up to 50%

- increased in older patients with larger tears


Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head


Shoulder High RIding Humersu





- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)


Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture




Deltoid avulsion


Axillary nerve injury


Acromial fracture


RC Tear / Anchor Pullout


Rotator Cuff Anchor Pull Out


Massive Tears

DefinitionsMassive RC Tear High Riding Humeral Head MRI


Massive tear 


1.  > 5cm 

- retracted to humerus / glenoid margin


2.  At least 2 complete tendons

- lose SS / IS or SS / SC





- SS + SSC


Postero-Superior defects

- SS + IS
- more common




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

- ff still have intact force couple often good function


Plan is to reproduce force couple 

- if tear is below equator of head 

- get uncoupling of cuff force couple

- lose cuff depressor effect & acts as head elevator


Integrity of coracoacromial arch integral component of repair

- acts as check rein to proximal migration 




Massive SS / IS wasting + rupture LHB

- weakness

- reduced active ROM

- atrophy


Shoulder Hiking due to massive cuff tearSupraspinatous and Infraspinatous wasting


2 classic signs


1.  ER lag sign


2.  Hornblowers

- 100% sensitive, 93% specific


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




Suprascapular nerve palsy

Brachial plexus injury

Cervical stenosis




Reduced acromiohumeral space

- < 7 mm RC tear

- < 5 mm massive tear


Rotator cuff OA

- acetabularisation


Decreased Acromioclavicular DistanceShoulder Massive Rotator Cuff Tear CTMassive Rotator Cuff Tear




1.  Level of retraction

- past coracoid irreparable


MRI Supraspinatous Retracted to Glenoid Margin


2.  Quantify fatty infiltration Goutallier


Parasagittal MRI T1

- atrophy and fatty replacement in SS / IS fossa


0 - no fat

1 - minimal fat

2 - more muscle than fat


Supraspinatous fatty infiltration grade 2


3 - fat equal muscle


MRI Fatty Infiltration Supraspinatous Infraspinatous


4 - more fat than muscle


Grade 4 Fatty Atrophy


3 & 4 have poor prognosis

- poor functional improvement with repair

- high incidence of retear


3.  Atrophy


Also poor prognosis


MRI Supraspinatous Atrophy




Non Operative


Physio /  HCLA

- improvement in 50-85%






A.  Primary repair / Debridement

1.  Mobilisation and repair

2.  Partial repair

3.  Decompression and debride

4.  Suprascapular nerve release


B.  Salvage

1.  Local tendon transfer - SSC

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

3.  Allograft

4.  Synthetic Graft

5.  Arthroplasty


Repair / Debridement


1.  Rotator Cuff Mobilisation and repair


Technique of mobilisation

- release coracohumeral ligament

- anterior slide (between SS and SSC)

- posterior slide (between SS and IS)

- release above glenoid 1 cm

- medialise insertion

- transosseous repair




Bigliani et al J Should Elbow Surg 1992

- 61 patients massive cuff tears followed up 7 years

- open repair

- 50% excellent and 30% good


2.  Partial repair



- restore balanced force couplet

- SSC + partial SS / IS repair

- act in conjuction to depress humeral head

- allow deltoid to work


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


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




Rhee et al Am J Sports Med 2008

- partial repair with interposition of biceps tendon to bridge gap

- MRI of 14 / 16 cases done arthroscopically

- complete healing in 60%


3. Decompress & debride alone



- doesn't restore power

- aiming for pain relief in elderly population



- maintain Coracoacromial arch to prevent humeral head escape

- don't perfrom SAD to preserve CA ligament

- debride cuff edges

- debride GT / tuberoplasty to decrease impingement

- biceps tenotomy / tenodesis




Boileau et al JBJS Am 2007

- demonstrated good results with tenotomy or tenodesis

- 61 patients with irreparable tears


Liem et al Arthroscopy 2008

- 31 patients average age 70

- debridement cuff edges + biceps tenotomy

- no SAD

- reasonable results


Walch et al Arthroscopy 2005

- arthroscopic tenotomy in 307 irreparable RC tears

- 87% satisfied with results


4.  Suprascapular nerve release



- retraction of cuff tethers / impinges SSN

- release of nerve arthroscopically relieves pain



- arthroscopic release

- see miscellaneous/suprascapular nerve for technique




Indications for tendon transfer / Graft


Young patient with poor function

- failed primary repair

- significant weakness

- good deltoid function

- CA arch intact / no superior escape

- good ROM

- either posterosuperior or anterosuperior defect


1.  Subscapularis Transfer



- may lose humeral depressor effect

- lose abduction with deltoid



- release upper 1/3 tendon from capsule




Karas et al JBJS Am 1996

- 20 patients

- good results in 17


2.  P.  Major Transfer



- functional deficit from SSC tear



- deltopectoral approach

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




Jost et al JBJS Am 2003

- reasonable results in isolated SSC

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


3.  Lat Dorsii Transfer



- IS / SS tear




Lateral Decubitus position

- arm over mayo table


Standard deltoid splitting open approach to subacromial space

- acromioplasty - minimal, preserve CA arch

- ACJ excision if needed

- tag cuff edges medially with sutures to augment repair

- place lateral anchors / sutures


L shaped incision

- inferior margin deltoid, lateral aspect of latissimus dorsi

- arm forward flexed to 90 degrees and IR

- infraspinatous usually very wasted

- identify T major

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

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

- place homan over humeral head

- release tendon from insertion / keep long

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

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

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

- tunnel tendon under deltoid & acromion

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

- repair with arm in abduction and ER

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


LDTT exposureLDTT intervalLDTT find tendon


LDTT homanLDTT tendonLDTT tendon suture


LDTT ReleaseLDTT humeral headLDTT repair


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




Miniacci JBJS Am 1999

- 14 / 17 good results regarding pain relief and ROM


Tauber et al JBJS Am 2010

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

- significantly improved results in bone block

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


4.  Allograft




Moore et al Am J Sports Med 2006

- 28 patients average age 59

- patella tendon or achilles

- sewn to tendon medially

- bone block laterally or sutured

- 15 repeat MRI - all complete failure of graft

- 1 infection and 1 allograft rejection

- similar functional results to debridement alone

- not recommended by authors


5.  Synthetic Allograft




Nada et al JBJS Br 2010

- dacron graft for massive cuff tears in 17 patients

- sutured medially, tied through bony tunnels laterally

- 90% satisfaction

- 15/17 intact on MRI

- 1 rupture, 1 deep infection


6. Arthroplasty


CTA Hemiarthroplasty / Reverse TSR

- salvage in patients > 65 years


Partial Thickness Tears



Pain & Stiffness

- often more pain than FT tears


Bursal side tears more painful than articular


Articular side more common


May see in young patient overhead throwing




Painful arc


Impingement signs


No weakness

- function good

- cable system intact




Articular sided more common than bursal



- A (articular)

- B (Bursal)


Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed




Sher et al JBJS Am 1995

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

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




Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT




Articular Sided


Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear


Bursal Sided




Articular side




Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear



- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage


PASAT Arthroscopy 1PASTA Arthroscopy 2


Bursal Sided


Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear




Non Operative


Physio / HCLA






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

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth




1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT


1.  Acromioplasty + debridement



- < 50% tears


Shoulder Scope PASTA Debridement




Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years


Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair


Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT



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

- repair > 50% especially in young patients


2.  Acromioplasty and repair


May be done open / arthroscopically / arthroscopically + mini open



A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open


A.  Convert to FT and repair


Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction


B.  Articular sided / transtendinous PASTA repair


Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation


Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair


C.  Bursal sided

- can repair top layer of tear only


Technique Transtendinous Arthroscopic PASTA Repair 



- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness




Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal


Shoulder Partial Articular Supraspinatous Tear PASTA


Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint


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


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

- tie to thread, and pass suture back through tendon

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


Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled


Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ


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


Post op

- can range aggressively

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

- prevents stiffness


Technique Open Articular PT Tears



- put spinal needle through torn portion

- pass suture through to mark tendon


Open approach over needle entry

- identify tear by suture

- convert to FT and repair


Technique Arthroscopic Bursal Sided Tear


Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion


Insert anchor

- pass sutures through top layer of torn tendon

- tie down


Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair

Revision Cuff Tears




- may be up to 50% retear over time

- many asymptomatic




Shoulder MRI Failed Rotator Cuff RepairShoulder MRI Failed RC Repair 2




1.  Debride / Biceps tenotomy or tenodesis


2.  Revision cuff repair

- open

- arthroscopic


Revision Rotator Cuff 1Revision Rotator Cuff Repair 2


3.  Tendon transfer







Subscapularis Arthroscopic Repair






- extra-articular



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

- port of Wilminton at anterolateral acromion to access SSC

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


SSC Repair Portals 1SSC Repair Portals 2



- identify tendon

- work through portal Wilmington

- grasp, forms comma sign

- perform biceps tenodesis

- tag SSC with fibrewire


SSC tornSSC comma sign


Subacromial space

- place standard lateral portal as well

- total bursectomy plus acromioplasty

- use tagging sutures to identify SSC

- release as necessary

- may need long posterior cannula to see anteriorly

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

- can use 70 degree scope


SSC Tagging Suture Subacromial SpaceSSC Debridement Anterior Subacromial


Prepare footprint

- debride

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

- pass sutures with suture passer

- tie


SSC Debride FootprintSSC First AnchorSSC Suture Passage


SSC Second AnchorSSC Repair




Subscapularis Tears

AnatomySSC Longitudinal Tear


Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus



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

- part of force couplet depressing humeral head




Can be isolated event


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

- anterosuperior tears




- biceps subluxation

- coracoid impingement





- hyperextension and ER






Pain anterior shoulder


Increased ER


Lift off test


Belly Press

- elbow falls posteriorly to harvest post deltoid




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




Complete absence of SSC


Subscapularis Retracted Tear Arthroscopy


Comma Sign


SSC tornSSC Comma Sign


Medially Subluxed Biceps


Medially Subluxed Biceps




Operative Indications



- failure of 6/12 non operative



- fix acutely



1.  Debridement

2.  Open Repair

3.  Arthroscopic Repair






Edwards et al Arthroscopy 2006

- 11 patients with SSC tears

- debridement

- tenotomy in 9 with dislocating / unstable biceps

- 9/11 good results


Open Repair




Deltopectoral approach

- preserve axillary nerve inferiorly

- mobilise SSC

- subscapular nerves on anterior surface medial to glenoid rim

- tenodesis LHB

- suture anchor repair to lesser tuberosity




Barti et al Am J Sports Med 2010

- 30 traumatic tears, patient average age 43

- associated biceps subluxation and HAGL's seen

- repair structurally intact in 93%

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

- these patients had higher degree of fatty infiltration preoperatively


Arthroscopic Repair


Intra-articular technique

- camera in GHJ

- anterosuperior portal

- mobilise tendon front and back

- must remove adhesions

- roughen insertion point on LT / gentle with burr as bone is soft

- insert twinfix anchors x 2 via stab incision

- pass birdsbeak suture passer through portal and through SSC

- retrieve 3 sutures through tendon

- retrieve 4th suture over top of SSC


Extra-articular Technique

- see article




Lafosse et al JBJS Am 2007

- isolated repair in 17 patients

- 15 intact repairs and 2 partial reruptures on CT arthrogram

- good outcomes


Late reconstruction


P. major transfer




Jost et al JBJS Am 2003

- good results in isolated SSC tears

- results poor in shoulder arthroplasty


Sternoclavicular Dislocations

EpidemiologySCJ Anterior DIslocation


Extremely uncommon

Stability provided by joint capsule /costoclavicular & interclavicular ligaments 


Recurrent instability uncommon


Many apparent dislocations in adolescents may be growth plate injuries 

-will remodel without treatment


If OA from chronic dislocation may resect SCJ




Anterior & posterior 



- more serious injury

- least common



- difficult on physical examination

- radiographs often are non diagnostic

- most consistent diagnostic modality = CT




SCJ CT Anterior DislocationSternoclavicular Anterior Dislocation


Usually managed non-operatively

- with activity modification and reassurance



- often will redislocate


Open reduction

- need to stabilise

- can use strip PL to stabilise

- uncertain if any benefit 




CT Posterior SCJ DislocationPosterior SCJ Dislocation CT


May require treatment because of proximity of major neurovascular structures and airway 


1.  Closed reduction

- performed under GA in operating room 

- chest surgeon available

- potential vascular / airway catastrophe associated with injuries to the mediastinum

- thorough vascular exam pre-operatively


2.  Assess stability


Successful closed reduction usually stable

- avoid internal fixation because of likelihood of hardware migration

- possible injury to the mediastinal structures


Closed reduction unsuccessful

- open reduction is indicated

- can stabilize with PL graft / intra-osseous sutures


SCJ Open ReductionSCJ Reduction 2SCJ Suture Fixation







TFCC tears

SL instability

Dorsal wrist ganglion

Scaphoid fracture with percutaneous pinning

Distal radius fracture






Finger Traps Index & middle


Overhead traction device


Wrist Scope set up


2.7 mm scope / small joint instrumentation

- insufflate with saline first at 3-4


Wrist Scope Insufflation


Radiocarpal Joint


RCJ is U shaped


Portals are between extensor compartments

- longitudinal incisions to protect extensor tendons

- blunt dissection to preserve SRN branches

- angle 30o volar due to shape distal radius


Wrist scope portalsWrist scope radiocarpal portal


3-4 Portal

- feel Lister's tubercle

- 1 cm distal is soft spot between 3 and 4

- between distal radius and scapholunate

- primary viewing portal


4-5 Portal

- roll finger over mobile 4th compartment

- feel soft spot

- slightly proximal to 3-4 because of slope of radius

- between distal radius and lunatetriquetral

- instrumentation


6-R and 6-U

- Named after their position about ECU

- 6-R working

- 6-U inflow


Midcarpal Joint




MCJ is S shaped

- midcarpal & radiocarpal have separate synovial cavities unless the SLL is torn


Midcarpal radial / MCR Portal

- 1 cm distal to 3/4 portal

- radial side of the third metacarpal axis 

- in line with Lister's tubercle

- soft depression between the capitate and scaphoid

- working portal


Midcarpal ulna / MCU Portal

- 1 cm distal to 4/5 portal

- in line with 4th metacarpal

- distal to lunate-triquetral joint

- proximal to capitate and hamate


Wrist scope portalsWrist Scope Midcarpal Scope


Radiocarpal Joint


Start at radial styloid and scaphoid

- work radial to ulnar


Distal radius


RSC Ligament

- immediately beside is Long RLL

- is extremely wide usually x3 RSCL

- next is short RLL

- often see blood vessels along this ligament


Scapholunate ligament

- examine from membranous prox portion to thicker dorsal ligamentous portion


Wrist scope SL Ligament Radiocarpal joint




Follow ulnarly along lunate and its fossa 

- should be taut like a trampoline 

- actual ballottement with probe should give same feeling 

- trampoline test


Wrist Scope TFCC


Examine for tears 

- central or peripheral

- ulnar styloid recess is normal finding at base of styloid not a tear


Lunate chondromalacia


Midcarpal joint


Curved of head of capitate


Wrist scope midcarpal joint


SL joint


Wrist scope midcarpal joint SL jointWrist scope Midcarpal Joint Normal SL ligament


Lunate-triquetral joint


Wrist Scope Midcarpal Normal Lunate Triquetrum


Specific Conditions


Carpal Instability


SL and LT Ligaments

- must look from radiocarpal and midcarpal joints

- both joint ligaments should be tight and concave

- if inflow in RCJ with midcarpal outflow have tear in ligament


Arthroscopic classification


1.  Attenuation or haemorrhage within ligament

- no step

- can debride partial tears with good results

- Rx cast immobilisation


II. Incongruency or step-off in midcarpal space

- Use k-wire as joy stick to reduce

- treat with arthroscopic pinning

- 80% reported good results


III. Step-off on both sides

- pprobe may be passed between bones

- treat with arthroscopic or open repair


IV. Gross instability

- open repair


TFCC Injuries


Use 4-5 portal as visual portal and 6-R as working portal



- degenerative or traumatic

- central or peripheral

- with or without DRUJ instability

- without or without chondromalacia

- radial or ulnar avulsions

- +/- Styloid fracture




Debride central tears acute or degenerative


Attempt repair of peripheral tears


Unstable DRUJ

- reinforce DRUL or PRUL with strip of ECU


Degenerative tear and ulnar plus 

- add ulnar shortening to debridement

- can perform arthroscopic wafer procedure

Base of Thumb OA



Degenerative arthritis at trapeziometacarpal joint (CMC)

- trapezoid - metacarpal




Commonest hand joint involved in OA 


Most common in older women                                      

- 90% are females > 50 years                                                

- asymptomatic degenerative changes common


Associated with arthritis in scapho-trapezial joint in 50%




1.  Trapeziometacarpal Joint (TMJ)

2.  Scaphotrapezial Joint (STJ)

3.  Trapeziotrapezoidal Joint

4.  Trapezium - Index Metacarpal Joint


The last two joints are rarely involved with OA


Saddle shaped

- allows movement in 3 planes

- flexion / extension

- adduction / abduction

- opposition


Volar, palmar oblique "beak" ligament

- provides stability of TMT

- origin is volar tubercle trapezium

- insertion ulna base of MC

- resists dorsal subluxation


Palmar 1/2 loaded > dorsal

- 13 x pressure with pinch






Combination of                                                                

- high compressive loads                                          

- relatively unstable joint                                              

- complex range of movement


May be related to ligamentous laxity





Rheumatoid arthritis                                              




Eaton Classification


Stage 1 


Joint normal with synovitis 


Stage 2 


Joint space narrowed                                                    

- may be mild subluxation (< 1/3) 


CMC OA Stage 2


Stage 3 


Joint space obliterated                                                


Subluxation base of thumb

- adducted position

- proximally is anchored by adductor pollicis

- base subluxes radially / beak ligament ruptured


CMC OA Stage 3


Stage 4 


Involvement of multiple joint surfaces especially STT joint


CMC OA Stage 4CMC OA Stage 4




Pain at base of thumb especially with pinch grip 


Becomes constant / difficulties with ADL 


Stiff thumb 


Weak pinch grip




Base of Thumb OA


Tenderness around CMC joint


Swelling from 

- synovitis 

- osteophytes 


Positive grind test 

- passive thumb circumduction and axial loading 

- causes pain 


Web space contracture

- fixed flexion-adduction contracture of 1st MC 

- compensatory MCPJ extension




De Quervain's

Radiocarpal OA


Scaphoid nonunion

Carpal tunnel syndrome 

FCR synovitis 

Volar ganglion

SRN neuroma




Nonoperative Management


Majority of patients do not require surgery




Rest / static splinting / thumb spica


Oral analgesics and NSAIDS


Intra-articular steroids / US guided


Operative Management


1.  Reconstruction of the volar ligament



- stage 1 disease

- non responsive to non operative management



- minimises progression of degenerative changes



- reconstruction of the volar ligament with slip FCR

- tendon passed through MC base and trapezium 

- create stabilising ligament (tenodesis) 


2.  CMC Arthrodesis



- stage II and III disease 

- young manual workers 

- ligamentous laxity and neurological conditions



- pantrapezial OA

- i.e. involvement of STJ



- pain-free 

- strong pinch 

- allows heavy use




1.  Limits mobility of thumb MC 

- loss of abduction / adduction

- unable to put palm flat on table


2.  Increases stress on adjacent joints 



- thumb position when fist made 

- 30-40o palmar abduction 

- 10-15o radial abduction



- dorsal incision at base of thumb over CMCJ

- dorsal to APL, between EPL and EPB

- protect SRN

- protect radial artery as it passes dorsally over STJ

- transverse incision capsule

- cut articular surfaces with saw

- ensure can pinch grip with IF / MF

- ensure can place across palm

- headless compression screws / plate

- POP for 6 weeks


3.  Hemitrapeziectomy


Removal of distal half of trapezium only


4.  Excisional arthroplasty / trapeziectomy


Thumb Trapeziectomy



- stage II & III disease

- no significant MC subluxation



- simple excision of trapezium



- simple procedure 

- minimal immobilisation



- shortening of thumb ray 

- weakness of pinch 

- thumb adduction



- trapeziectomy without interposition / ligament reconstruction

- no evidence has worse results than any other more complicated procedure


5.  Trapeziectomy and LRTI



- stage III and IV disease 



- trapeziectomy +

- ligament reconstruction of beak ligament with FCR / PL

- tendon interposition (FCR / PL / Capsule)


Supposed Advantages

- maintains strength / pinch grip

- prevents shortening



- tendon harvest

- longer / more involved procedure

- no evidence of improvement of pinch grip / prevention of shortening





- dorsoradial

- junction of volar and dorsal skin



- protect SRN

- between APL and opponens

- radial artery over ST Joint 

- open capsule over trapezium 

- elevate thenar muscles from trapezium and 1st MC 


Excise trapezium 

- remove bone piecemeal / or in one piece 

- take care not to damage underlying FCR 


LRTI Technique 1


Make hole in base of MC 

- perpendicular to plane of thumbnail 

- from radial cortex to base 


Harvest lateral half FCR

- 10 - 12 cm strip

- 2 - 3 transverse incisions in forearm over FRC

- split all the way to base of second MT

- pass through base second MT then radial cortex

- pass around base to resurface

- suture to itself whilst pushing MC base medially


Make spacer 

- anchovy tendon on itself 

- insert it into trapezium fossa 


Stabilise with K wire

- MC reduced and out to length


Close wound & apply thumb spica 



- ROS and K wire at 10 days 

- splint for another 3 weeks 

- progressive exercises


LRTI Technique 2


Harvest PL

- leave attached distally

- pass into base of thumb under FCR to where trapezium used to be

- ligament suspension by passing through radial capsule and FCR multiple times

- tightens the capsule and FCR into the gap


Capsular interposition technique


Open capsule as a distally base flap

- after trapeziectomy suture into base of wound as interposition



- > 90% satisfactory results long-term 

- > 95% pain relief

- > 90% increased grip strength

- average loss of height is 13% at 9 years


6.  Silicone replacement arthroplasty



- stage III and IV disease 

- low-demand patient

- rheumatoid



- trapeziectomy

- insert silicone trapezium



- retains movement at CMC joint



- subluxation or dislocation 

- prosthesis breakage (50% at 4 years) 

- silicone synovitis 



- address subluxation by soft tissue reconstruction 

- strip of APL can be passed through hole in prosthesis 


7.  Joint replacement


High revision rate

- pain

- lysis

- loosening


Carpal Instability




Loss of normal ligamentous and / or bony constraints of wrist




Overall alignment maintained by extrinsic and intrinsic  ligaments


1.  Intrinsic ligaments


Carpal bone to carpal bone

- support the lunate in a balanced position


A.  Scapho-lunate ligaments


SL ligament can be divided into three different zones

- dorsal ligamentous zone (structurally the most important)

- palmar ligamentous zone 

- proximal membranous fibrocartilaginous zone


B.  Luno-triquetral ligaments 

- also 3 components

- volar most strong


2.  Extrinsic Ligaments


Radius to carpus 

- obliquely oriented

- resist the tendency of the carpus to migrate ulnarly and palmarly


A.  Palmar extrinsic ligaments


A. Radioscaphocapitate ligament

B. Radiolunate ligament

C. Radioscapholunate ligament

- probably just a vascular fold

D. Ulnocarpal ligaments

E. Lunotriquetral ligament


Space of Poirier

- weak area of the palmar ligaments


B.  Dorsal Extrinsics


A. Dorsal radiotriquetral ligament / Dorsal radiocarpal ligament (DRC)

B. Dorsal radioulnar ligament

C. Triquetroscaphoid ligament / Dorsal intercarpal ligament (DIC)


No tendons attach to proximal row



- acess to dorsal carpus

- raise a radially based flap

- between radiotriquetral and triquetroscaphoid

- between DRC and DIC






Capitate is centre of rotation


Flexion / Extension

- 120o

- 50% midcarpal

- 50% radiocarpal


Radial / ulna deviation

- 60% midcarpal

- 40% radiocarpal


Radial deviation

- 20o

- proximal row and scaphoid flexes


Ulnar deviation

- 30o

- proximal row and scaphoid extends


Load transfer


Radius 80%

Ulna 20% (all via TFCC)




Division of the scapholunate ligament 

- allows the lunate to follow the triquetrum's unrestrained position of extension

- dorsal intercalated segmental instability pattern (DISI)

- scaphoid flexes, lunate extends


Lunotriquetral ligament disruption 

- allows the lunate to follow the scaphoid into its position of unrestrained flexion

- lunate flexes

- volar intercalated segmental instability pattern (VlSI)


Classification of Carpal Instabilities (Amadio)


I. Carpal instability dissociative (CID)


Transverse injury


Injury inter-osseous ligaments

- within the carpal rows

- disassociative rather than associative motion between the bones of each row


A.Dorsiflexion (DISI)

- scapholunate ligament injury


B. Palmar flexion (VISI)

- triquetrolunate injury


II. Carpal instability non-dissociative (CIND)


Transverse injury


Normal associative motion between the bones of each carpal row 

- the dissociation is between rows


A. Radiocarpal Dislocation


CIND Dislocated Radiocarpal Joint APDislocated Radiocarpal Joint lateral


Radiocarpal Dislocation CT 1Radiocarpal Dislocation CT 2Radiocarpal Dislocation CT 3


B. Midcarpal


C. Ulnar Translocation




Secondary to radial malunion

- treat with radial osteotomy if symptomatic


DISI CIND Secondary Radial Fracture




Secondary to ligamentous laxity

- non operative treatment

- no progression to OA


Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation


III. Carpal instability complex (CIC)


Hyperextension injury


As the hand is forced into hyperextension

- ulnar deviation and intercarpal supination

- the ligamentous disruption


Mayfield Cadaver study 

- extend, ulna deviate, supinate


Stage 1 

- SL dissociation 


Stage 2

- CL dissociation 

- capitate dislocates


Stage 3

-  LT dissociation


Stage 4

-  Lunate dislocates




A. Perilunate Dislocation

1. Dorsal (10%)

2. Volar (90%)


B. Trans-scaphoid Perilunate


IV. Carpal instability longitudinal (axial)


Longitudinal injury


The carpus may also be disrupted in a longitudinal fashion, as opposed to the perilunate transverse pattern




A.  Axial Ulnar (AU)

B.  Axial Radial (AR)

C. Axial Ulnar-Radial (AUR) / Combined


These are severe injuries

- crush, blast or compression

- may be open injuries

- not a diagnostic dilemma


Usually wrist is split into two columns

- metacarpals follow their corresponding carpus




Deal with wounds and nerve / tendon injuries


K wire fixation


Greater and Lesser Arc Injuries


Greater arc injury

- fracture-dislocation of the scaphoid, capitate, hamate, triquetrum

- may include radial styloid


Lesser arc injury 

- a pure ligamentous injury

- around the lunate






Radiocarpal & Midcarpal Dislocation

A. Radiocarpal Dislocation


Dislocated Radiocarpal Joint Dislocated Radiocarpal Joint AP


Dislocated Radiocarpal Joint CT 1Dislocated Radiocarpal Joint CT 2Dislocated Radiocarpal Joint CT 3


Dorsal Radiocarpal Dislocation ORIF 1Dorsal Radiocarpal Dislocation ORIF 2


B. Midcarpal Dislocation



SLAC Wrist


SLAC Wrist


Scapho-lunate advanced collapse

- caused by malalignment of scaphoid on radius

- due to scapholunate disruption


Most common cause of wrist OA




1.  Radio-scaphoid degenerative changes

- from abnormal flexion of scaphoid

- scaphoid fossa is elliptical causing incongruence with flexion of proximal scaphoid

- loads scaphoid fossa of radius peripherally


2.  Radiolunate joint preserved

- lunate fossa and proximal lunate spherical and congruent


3.  Capitate under increasing load descends into gap

- increasing loads on capitolunate joint

- separation of scaphoid and lunate

- capitate shears off radial edge of lunate

- get destruction on both lunate and proximal capitate 




OA radio-scaphoid joint

Preservation of radiolunate joint




1.  Styloid OA


Stage 1 SLAC Radial Styloid OA


2.  Scaphoid Fossa OA




3.  Lunato-capitate OA

- capitate descends in SL gap


SLAC Lunate Capitate OA


4.  Pancarpal OA





- preservation of scaphoid fossa and proximal scaphoid congruence

- arthritis at scapho-capitate joint




Stage 1



- styloid OA

- degeneration between the radial styloid and distal pole scaphoid




1.  Styloidectomy

- early disease can respond well to styloidectomy

- remove at level A / no removal of scaphoid fossa


2.  Scapholunate Reconstruction 


A.  Excise fibrous tissue and insert SL screw

- fibrous ankylosis

- remove screw at 12/12


B.  Bone blocks with ligament


Stage 2 



- scaphoid fossa OA

- OA extends to involve scaphoid fossa and proximal pole scaphoid




A.  Scaphoidectomy & four corner fusion

B.  Proximal Row Carpectomy


Scaphoidectomy & Four Corner Fusion


Scaphoidectomy and 4 corner fusion



- fusion of lunate to capitate

- loading is through normal lunate fossa

- fusion of lunate-capitate can be difficult

- add hamate and triquetrum in so called 4 corner fusion

- greatly increases fusion rates

- seemingly no deleterious effects

- if leave out scaphoid replacement tends to drift into radial deviation

- can use scaphoid for bone graft (but may not be high quality)



- increased stability comared with PRC

- increased ROM compared with total wrist arthrodesis



- universal posterior approach

- base of EPL (3/4 interval)

- can use Lister's tubercle for BG

- make window on radial side so as not to get late rupture of EPL

- denervate wrist / remove terminal branch PIN

- ligament sparing exposure / open capsule between dorsal intercarpal and radiocarpal

- closure ER under EPL at end of case



- resect scaphoid

- denude surfaces of lunate / capitate / hamate / triquetrum

- use good quality BG from distal radius

- must reduce the lunate out of extension or will impinge dorsally


Scaphoidectomy 4 corner Fusion APScaphoidectomy 4 corner Fusion Lateral



- headless compression screws

- dorsal circular plate

- K wires



- strength 75-80% normal

- ROM 40 - 60% of normal


B.  Proximal row carpectomy


Proximal Row Carpectomy



- for capitate to articulate with distal radius



- proximal capitate often devoid of good cartilage

- discard good lunate cartilage

- weakness ensues due to lengthening of tendons

- reported pain / instability / degeneration



- probably best in low demand patients

- not in stage 3 SLAC



- perform through standard dorsal approach



- RCT of 4 corner fusion v PRC are comparable


Stage 3 




Capito-lunate OA 

- capitate migrates proximally between the scaphoid and the lunate




A. Scaphoid excision & 4 corner fusion

B. Proximal Row Carpectomy

C. Wrist Arthrodesis



- PRC may be bad options in stage 3

- they depend on the capitate and by definition the capitate is arthritic


Stage 4




Collapse / pancarpal OA




Wrist arthrodesis



Scapholunate Ligament Injury / DISI

Scapholunate Disassocation




Dorsal Intercalated Segmental Instability / CID




Scapholunate joint

- C shaped

- 2-3 mm thick dorsally with transverse fibres

- thin palmar


Dorsal extrinsic ligaments

- V shaped, onto trapezium


1.  Dorsal RC ligament / DRC

- radius to triquetrum


2.  Dorsal Intercarpal Ligament / DIC

- trapezius to scaphoid


Between these two ligaments is access to SL joint


Volar extrinsic ligaments



- ligament of Testut




Most common form of carpal instability







- SL diastasis



- positive Kirk Watson test

- nil SL diastasis without dynamic / stress imaging



- secondary to radial malunion

- adaptive posture of proximal row

- lunate extends

- capitate translates dorsally and get OA

- treat with radial osteotomy if symptomatic






Scapholunate dissociation

- Mayfield Stage 1


Wrist extended / ulna deviated / supinated

- capitate driven into interval between scaphoid and lunate




CID (Complex Instability Dissociative)

- disassociation between scaphoid and lunate

- Palmarflexion of scaphoid

- dorsiflexion of lunate


The scaphoid will move into flexion

- due to its ligamentous attachments to the distal carpal row


Lunate extends

- due to ligamentous attachment to triquetrum




History of injury 

Pain on radial side of wrist 

Weakness of wrist 


Certain movements may cause clicking or snapping




DR / scaphoid fracture




STT, wrist, RC OA




Swelling and tenderness over SLJ

- most specific 


Pain with dorsiflexion and radial deviation


Kirk-Watson test 


Kirk Watson Test 1Kirk Watson Test 2


1.  Passive wrist ulnar deviation

- thumb on dorsum wrist / index finger on scaphoid tuberosity 

- in wrists with instability, the scaphoid is displaced dorsally over the lip of the radius


2.  Passive wrist radial deviation 

- the scaphoid's proximal pole returns to its position in the scaphoid fossa of the radius 

- as the scaphoid reduces, a clunking sensation and wrist pain are noted


1000 randomly examined wrists 

- 11% had unilateral, asymptomatic increased scaphoid mobility on KW test


Patients with dynamic instability are distinguished by

- symptoms of instability and pain with KW test




Look for signs of SLAC wrist

- degenerative changes of scaphoid fossa with relative sparing lunate fossa

- indicates long standing




Terry Thomas sign 

- increased scapholunate interval 

- > 3 mm compared with other side


Scapholunate diasstasis


Stress views

- bilateral wrists clenched 

- in ulnar deviation 

- in radial deviation 

- may show Terry Thomas sign


Cortical Ring sign 

- end-on view of cortex of distal pole of scaphoid


Scapholunate Disassocation Cortical Ring Sign


Scaphoid shortened

- due to palmar flexion


SL injury shortened scaphoid




Palmarflexion of scaphoid 


Dorsiflexion of lunate 


Increased scapholunate angle 

- > 70o

- usually 30 - 60o


Scapholunate Angle IncreasedScapholunate Angle IncreasedIncreased Scapholunate Angle


Increased luno-capitate angle

- normally < 10o


Scapholunate Injury Increased Lunate Capitate AngleIncreased Scapholunate Angle


Increased radio-lunate angle

- normally < 10o

- lunate extended > 10o




Can demonstrate tear

- need experienced radiologist

- need MRI in correct plane

- sensitivity may be as low as 40%




Best method of diagnosis

Gold Standard


Acute Management




Within 3-6 weeks





- immobilise 6 / 52



- SL diastasis

- usually torn off scaphoid

- repair





- dorsal midline approach

- 3 / 4 interval (3rd and 4th extensor compartments)

- open capsule between DRC and DIC ligaments

- radially based flap



- K wires into scaphoid and lunate

- use as joystick to reduce

- extend scaphoid, some flexion of lunate

- K wire fixation to hold in place (SL and SC x 2)

- neutralises rotational forces during healing



- micro anchors ain scaphoid

- or can place drill holes in scaphoid to pass sutures

- 2.0 ethibond


+ / - Augmentation

- Blatt capsulodesis

- SL screw / pseudoarthrosis


Post op

- 8 weeks POP

- remove K wires

- patient will lose some ROM






> 12 weeks 




Failed reconstruction / missed injury


Failed Scapholunate Reconstruction


Surgery only for significant disability 

- no reconstructive technique excellent

- inconsistent results, loss of reduction, loss of pain relief over time




Ligament repair

Ligament reconstruction

Blatt capsulodesis

Reverse Blatt capsulodesis

Brunelli Tendodesis

Limited wrist fusion


1.  Ligament repair and capsulodesis


Sufficient tissue available for repair

Reinforce with Blatt capsulodesis


2.  Ligament reconstruction


Scapholunate Ligament Reconstruction APScapholunate Ligament Reconstruction Lateral


3.  Blatt Capsulodesis



- chronic DISI with insufficient tissue for repair

- to augment ligament repair

- dynamic instability



- dorsal, proximally based capsular flap 1 cm wide

- reduce scaphoid out of flexion and K wire (SL / SC)

- suture anchor distal pole scaphoid and attach capsular flap

- prevents flexion of scaphoid

- may combine with SLL reconstruction with PL


Post op

- plaster for 2/12

- removal K wires


The patients end up with a stiff wrist


4.  Reverse Blatt



- leave capsule attached distally

- advance proximally

- limits wrist flexion


5.  Brunelli Wrist Tenodesis


Harvest half FCR

- pass volar to dorsal through hole distal scaphoid

- insert dorsally into distal radius

- serves to derotate scaphoid


6.  Limited fusion 


Radial styloidectomy and STT fusion



- stabilise scaphoid in extended position


Kleinman J Hand Surg Am 1998

- no progression of arthritis seen in 16 wrists






Volar Intercalated Segmental Instability

- secondary to injury to the lunate-triquetral ligament




Less common




Caused by fall on outstretched extended wrist

- hypothenar eminence strikes ground first 

- isolated LT ligament injury


Can be part of perilunate dislocation

- SL heals

- residual LT laxity




LT ligament

- also C shaped

- strongest palmar





- scaphoid imparts a flexion moment on proximal row

- triquetrum imparts an extension moment

- balanced by ligamentous attachments to lunate


Palmarflexion of lunate with dorsiflexion of triquetrum


Probably need injury to dorsal extrinsics to impart static collapse

- DRC ligament (radio-triquetral)

- ulnocarpal ligament












Secondary to ligamentous laxity

- seen in teenage girls

- clunk on radial and ulna deviation with axial compression


Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation


Non operative treatment

- no progression to OA




History of injury 


Pain on ulnar side of wrist 


Weakness of wrist




Swelling and tenderness over triquetro-lunate joint 


Ulna deviation / pronation / axial compression

- pain and clicks


Reagan Ballotment 

- Triquetro-lunate ballottement

- pisiform-triquetral with thumb and index finger

- lunate with other hand


Lunate Triquetral Ballotment




DRUJ instability

TFCC tear

Ulna head OA

Pisiform triquetral OA

Hamate fracture

ECU subluxation


AP Xray


Palmarflexion of scaphoid 

- Scaphoid shortened 

- Ring sign 


Palmarflexion of lunate 

- Appears triangular 

- Triquetrum distally displaced 


Broken Shenton's line (of proximal carpal row)


Lateral Xray


Decreased scapholunate angle 

- < 30o


Palmarflexion of lunate 

- capitate - lunate angle > 10o

- radio - lunate angle > 10o




Diagnostic and therapeutic