American Shoulder and Elbow Surgeons
Please rate topic.
Average 4.2 of 34 Ratings
Which of the following patients may benefit from a lesser tuberosity transfer (modified McLaughlin procedure)?
A kidney transplant recipient with AVN of the humeral head
A patient with severe rheumatoid arthritis
A young man with a locked posterior dislocation following an electric shock injury at work
A patient with a history of previous shoulder surgery that now has subscapularis insufficiency
A patient with a large Hill-Sachs defect following an anterior shoulder dislocation
Select Answer to see Preferred Response
Forceful posterior glenohumeral dislocations such as those resulting from seizures or electric shock may sustain a large reverse Hill-Sachs defect resulting in persistent instability in internal rotation or a locked posterior dislocation. These patients may benefit from having the lesser tuberosity along with the subscapularis advanced into the bony defect on the anterior humeral head (modified McLaughlin procedure). The original description by McLaughlin involved transferring the subscapularis tendon into the defect, and was later modified and popularized by Neer who recommended transferring the lesser tuberosity with the subscapularis.
Finkelstein et al reported good functional results using this procedure acutely in 7 patients who were unstable in internal rotation and had an anteromedial impaction fracture occupying 25-40% of the articular surface.
Hawkins et al descibe various treaments for locked posterior dislocations. All 4 of their patients with a lesser tuberosity transfer did well and they suggest using it when closed reduction fails for smaller defects and for moderate defects with head involvement of 20-45%.
A CT scan showing a posterior dislocation with large reverse Hill-Sachs lesion in shown in Illustration A. The post-op CT scan after open reduction and lesser tuberosity transfer into the defect is seen in Illustration B.
None of the other patients meet the accepted indications for this stability procedure.
1. & 2. May benefit from other procedures such as a shoulder arthroplasty.
4. May benefit from subscapularis repair or pectoralis tendon transfer to restore function.
5. A Hill-Sachs defect is on the posterior superior aspect of the humeral head and may benefit from bone grafting or remplissage, but not a lesser tuberosity transfer.
Finkelstein JA, Waddell JP, O'Driscoll SW, Vincent G.
J Orthop Trauma. 1995 Jun;9(3):190-3. PMID: 7623169 (Link to Abstract)
Finkelstein, JOT 1995
Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX.
J Bone Joint Surg Am. 1987 Jan;69(1):9-18. PMID: 3805075 (Link to Abstract)
Hawkins, JBJS 1987
Please rate question.
Average 4.0 of 29 Ratings
A 26-year-old football offensive lineman presents with shoulder pain which is affecting his ability to block effectively. On exam, he has a positive jerk test and a positive Kim test. What is his most likely diagnosis?
Posterior labral tear
The posterior jerk test is a sensitive exam for ascertaining the presence of posterior glenoid labral tears in the mid-range of the glenoid. The Kim test is more sensitive for posterior-inferior labral tears. This is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus. The test is positive when pain is present. When the jerk test and Kim test are combined, there is 97% sensitivity in detecting a posterior labral tear.
Escobedo et al performed a retrospective study of 166 shoulder MRI arthrograms from patients who had presented with shoulder pain and/or instability. They selected out 20 competitive football players and 20 age-matched controls. 55% of the football players had at least one posterior labral tear, while only 10% of the matched non-football players had a posterior labral tear, which was statistically significant.
Acronyms are commonly used to describe injuries in sports medicine and may be tested with either the short or long name: SLAP=superior labrum anterior-posterior; ALPSA=anterior labral periosteal sleeve avulsion; PASTA=partial articular-sided supraspinatus tendon avulsion.
Illustration A demonstrates the Kim test.
Escobedo EM, Richardson ML, Schulz YB, Hunter JC, Green JR 3rd, Messick KJ.
AJR Am J Roentgenol. 2007 Jan;188(1):193-7. PMID: 17179364 (Link to Abstract)
Escobedo, AJR 2007
Arthroscopic treatment of reverse Bankart tear for posterior instability.
Average 4.0 of 11 Ratings
An acute posterior shoulder dislocation should be suspected in a patient with pain and the shoulder locked in what position?
Patients with posterior shoulder dislocations are often overlooked. They present with the shoulder locked in internal rotation and adduction and lack external rotation. Orthogonal radiographs (anterior-posterior and axillary lateral) are absolutely necessary for proper diagnosis. Posterior dislocation patients often have reverse Bankart and reverse Hill-Sachs lesions.
Ivkovic et al. reported a case of bilateral posterior dislocations successfully treated with hemiarthroplasty and osteochondral allograft.
Longo et al performed a systematic review of 31 randomized controlled trials and concluded primary surgery is favorable in young adults engaged in highly demanding sports or job activities. However, there is lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injury.
Paul et al found 9 Level 4 articles in the evidence-based literature regarding posterior shoulder dislocation management. The size of the humeral head impression fracture is key for decision making. The algorithm in Illustration A provides treatment guidelines according to the size of the lesion. Nonoperative treatment can confer satisfactory results for older, lower demand patients or those with unstable epilepsy. However, surgical treatment is recommended to achieve good functional results in other patient populations.
Ivkovic A, Boric I, Cicak N
J Bone Joint Surg Br. 2007 Jun;89(6):825-8. PMID: 17613513 (Link to Abstract)
Ivkovic, BJJ 2007
Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V.
Arthroscopy. 2014 Apr;30(4):506-22. PMID: 24680311 (Link to Abstract)
Longo, ASCOPY 2014
Paul J, Buchmann S, Beitzel K, Solovyova O, Imhoff AB.
Arthroscopy. 2011 Nov;27(11):1562-72. Epub 2011 Sep 1. PMID: 21889868 (Link to Abstract)
Paul, ASCOPY 2011
Average 3.0 of 12 Ratings
A football player subluxates his shoulder while blocking with his arm forward flexed and internally rotated. The “Jerk” test is positive. What is his most likely pathology?
Glenohumeral internal rotation deficit
This football player likely suffered a posterior inferior labral tear, also known as a Kim lesion, or a Reverse Bankart lesion. The Jerk test is where a posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. This will cause the humeral head to subluxate posteriorly out of the glenoid socket. As the arm is brought into extension, a clunk will be felt as the humerus reduces into the glenoid cavity. A Hill-Sachs lesion is a bony humeral impaction lesion from an anterior dislocation, glenohumeral internal rotation deficit (GIRD) is found in throwers who have a tight posterior-inferior capsule and lack internal rotation, an acromioclavicular separation has pain over the AC joint and may have a positive piano key sign when the clavicle “pops” up with arm depression.
The review by Millett describes the history, exam, and radiologic findings of posterior shoulder instability.
The Kim paper describes the injury which bears his name.
Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ.
J Am Acad Orthop Surg. 2006 Aug;14(8):464-76. PMID: 16885478 (Link to Abstract)
Millett, JAAOS 2006
Kim SH, Ha KI, Yoo JC, Noh KC
Arthroscopy. 2004 Sep;20(7):712-20. PMID: 15346113 (Link to Abstract)
Kim, ASCOPY 2004
Average 3.0 of 19 Ratings
Posterior glenohumeral dislocations are as common as anterior dislocations in which of the following patient groups?
Marfan's syndrome patients
Renal failure patients
Millett et al and Robinson et al provide review articles on posterior shoulder dislocations, which are rare clinical entities that occur during seizures and electrocution (due to tetanic muscle contraction) or as a result of high energy trauma. Robinson et al noted that poor prognostic factors associated with posterior shoulder dislocation include late diagnosis, large bony defect of humeral head, associated proximal humerus fracture, and need for arthroplasty. In Gerber's series, posterior dislocations occurred with equal frequency to anterior in a cohort of epilepsy patients.
Robinson CM, Aderinto J.
J Bone Joint Surg Am. 2005 Apr;87(4):883-92. PMID: 15805222 (Link to Abstract)
Robinson, JBJS 2005
Bühler M, Gerber C
J Shoulder Elbow Surg. 2002 Jul-Aug;11(4):339-44. PMID: 12195251 (Link to Abstract)
Bühler, JSES 2002
Average 3.0 of 16 Ratings
A 35-year-old man awoke following a night of heavy drinking with severe right shoulder pain and inability to raise his arm above his head. A radiograph from the emergency room is provided in Figure A. He was treated with a sling for a diagnosis of rotator cuff tear. Six weeks later, he complains of continued pain and difficulty using the arm. Which of the following is the next best step in management?
Physical therapy for range of motion followed by rotator cuff and deltoid strengthening exercises
Axillary radiograph of the shoulder
EMG to evaluate the suprascapular and axillary nerves
Arthroscopic rotator cuff repair
Open subacromial decompression and latissimus dorsi transfer for massive cuff tear
The radiograph demonstrates overlap of the humeral head and glenoid suggesting shoulder dislocation. An Axillary radiograph is necessary to evaluate concentric reduction vs. dislocation of the shoulder. An example is provided in illustration A. Posterior shoulder dislocations can be easily be missed without the proper orthogonal views of the shoulder. Perron reviews the proper identification and emergency room care of posterior shoulder dislocation. Richardson found axillary radiographs to be more sensitive than trans-scapular radiographs for identifying posterior shoulder dislocations.
Perron AD, Jones RL.
Am J Emerg Med. 2000 Mar;18(2):189-91. PMID: 10750929 (Link to Abstract)
Richardson JB, Ramsay A, Davidson JK, Kelly IG.
J Bone Joint Surg Br. 1988 May;70(3):457-60. PMID: 3372570 (Link to Abstract)
Richardson, BJJ 1988
Average 4.0 of 15 Ratings
A football linemen has posterior shoulder pain after making a block with his arm in forward flexion and internal rotation. What is the most likely diagnosis?
Superior labral tear
Humeral avulsion of the glenohumeral ligament (HAGL)
This is the most common shoulder position for posterior instability. Compared with anterior shoulder instability, posterior instability is relatively uncommon with an overall reported incidence rate between 2% and 12% of all cases of shoulder instability. The majority of patients will complain primarily of pain, with instability as a secondary concern. Symptoms are caused by an abnormal posterior translation of the humeral head relative to the glenoid surface. Symptoms may be reproduced by performing the posterior load and shift test. The examiner stands at the side of the patient while stabilizing the scapula, the affected arm is flexed forward to 90 degrees and internally rotated and then a posteriorly directed force is applied. This can also be done with the patient supine with the medial scapula stabilized by the edge of the table.
Bradley et al performed a Level 2 study of 99 arthroscopic posterior labral repairs and found that it is an effective, reliable treatment for symptomatic unidirectional recurrent posterior glenohumeral instability with 89% of patients were able to return to sport.
Williams et al reviewed their data on 27 posterior labral repairs and found that symptoms of pain and instability were eliminated in 24 patients (92%).
Bradley JP, Baker CL, Kline AJ, Armfield DR, Chhabra A
Am J Sports Med. 2006 Jul;34(7):1061-71. PMID: 16567458 (Link to Abstract)
Bradley, AJSM 2006
Williams RJ 3rd, Strickland S, Cohen M, Altchek DW, Warren RF.
Am J Sports Med. 2003 Mar-Apr;31(2):203-9. PMID: 12642253 (Link to Abstract)
Williams, AJSM 2003
Average 4.0 of 12 Ratings
A 63-year-old diabetic female complains of left shoulder pain and decreased range of motion 7 months after a fall onto her left side. On physical examination she has marked decrease in external rotation. A radiograph obtained earlier that day at her primary care office is displayed in Figure A. What is the next step in management?
Physical therapy for adhesive capsulitis secondary to chronic 2-part humeral head fracture
Proximal humeral arthroplasty
Obtain further radiographic studies
Open reduction and internal fixation of the chronic 2-part humeral head fracture
Sling immobilization for 10-14 days then begin physical therapy for chronic 2-part humeral head fracture
Further radiographic studies are required including an axillary view. The humeral head resembles a "light bulb", indicating a possible posterior shoulder dislocation. Illustration A is an axillary view of this patient confirming chronic two-part fracture-dislocation of the anatomical neck of the humerus.
The Level 4 study by Hawkins and Neer describe their experiences with 41 locked posterior dislocations of the shoulder with 50% having an associated fracture. Twenty of the dislocations were missed diagnoses by treating physicians and the average time from injury to diagnosis was 1 year. Hawkins and Neer conclude treatment is determined by the duration of time the shoulder has been dislocated and the size of the humeral head defect, (reverse Hill-Sachs lesion).If the dislocation is less than 6 weeks old AND the defect involves less than 20% of the articular surface, then closed reduction should be attempted. If the dislocation is 6 weeks to 6 months old AND the defect involves 20 to 45% of the articular surface, transfer of the lesser tuberosity (McLaughlin procedure) should be done. If the glenoid is normal and the dislocation is more than 6 months old OR the defect involves more than 45% of the articular surface, or both, a hemiarthroplasty should be done. A hemiarthroplasty is indicated as treatment in this patient's case after obtaining full radiographs. It should be noted that adhesive capsulitis (option 1) does cause pain and loss of range of motion, especially with external rotation.
Average 3.0 of 23 Ratings
A 25-year old female with a seizure disorder complains of persistent left shoulder pain after sustaining a seizure 1 week ago. She was placed in a sling in the ER and is following up in your office. Figure A shows the radiograph taken in the ER. On examination, her range of motion is limited and is only able to externally rotate to neutral. What is the next step in management?
Sling use for comfort and follow-up in 2 weeks
Repeat True AP radiograph
Axillary lateral radiograph
MRI of the shoulder
Intra-articular cortisone injection with range of motion exercises
This question tests the concept that posterior shoulder dislocation is frequently missed due to inadequate imaging. Trauma shoulder radiographs (which include an AP, axillary, and scapular Y view) must be obtained in all suspected shoulder dislocations.
Posterior dislocations are more common following a seizure. The posteriorly dislocated shoulder is typically held in IR and most consistent finding is a mechanical block to ER caused by the anterior humeral head defect on the posterior aspect of the glenoid.
According to the reference by Robinson et al, good functional outcomes are associated with early detection and treatment of isolated posterior dislocations that are associated with a small osseous defect and are stable following closed reduction.
Robinson CM, Aderinto J
J Bone Joint Surg Am. 2005 Mar;87(3):639-50. PMID: 15741636 (Link to Abstract)
Average 4.0 of 14 Ratings
Posterior Shoulder Instability and Posterior Labral Tear Michael Bahk, MD
Session III Shoulder continued Author: Anthony A. Romeo, MD Duration: 11:59
Video demonstrating arthroscopic posterior shoulder stabilization
video of Dr. Don Buford's surgical technique for posterior shoulder instability...
HPI - 58M, s/p motorcycle accident 5 weeks ago.
Isolated LEFT shoulder injury.
Has pain and limited function of left shoulder.
Was seen in ER were he was told x-rays where normal, and now follows up after PMD ordered MRI of shoulder.
Shoulder was normal prior to accident.
What x-ray view would have aided in the initial treatment of this patient?
HPI - 65 yo M alcoholic complains of multiple shoulder dislocations. Most recent dislocation occurred 2 months ago and he has been unable to use the arm for the past 2 months.
Treatment for this chronic posterior shoulder dislocation?