Introduction Also referred to as AMBRI Atraumatic Multidirectional Bilateral (frequently) Rehabilitation (often responds to) Inferior capsular shift (best alternative to nonop) Epidemiology incidence peaks in second and third decades of life Pathophysiology mechanisms underlying mechanism includes microtrauma from overuse seen with overhead throwing, volleyball players, swimmers, gymnasts generalized ligamentous laxity associated with connective tissue disorders: Ehlers-Danlos and Marfan's pathoanatomy hallmark findings of MDI Imaging findings: patulous inferior capsule on MRI (IGHL anterior and posterior bands) rotator interval deficiency labral lesions or glenoid erosion can still occur from traumatic events Bankart lesion is anteroinferior labral tear Kim lesion is posteroinferior labral avulsion Anatomy Glenohumeral stability static restraints glenohumeral ligaments (below) glenoid labrum (below) articular congruity and version negative intraarticular pressure if release head will sublux inferiorly dynamic restraints rotator cuff muscles the primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by compressing the humeral head against the glenoid biceps periscapular muscles Complete Glenohumeral anatomy Presentation Symptoms pain instability weakness paresthesias crepitus shoulder instability during sleep Physical exam Tests - must have instability in 2 or more planes (anterior, posterior, or inferior) to be defined as MDI sulcus sign (2+ or more) assesses rotator interval laxity of rotator interval presents as increased external rotation with the arm abducted apprehension/relocation test anterior and posterior load and shift test (2+ or more) Neer and Hawkins test impingement or rotator cuff tendonitis in <20 year old signals possible MDI signs of generalized hypermobility - generalized ligamentous laxity = Beighton's criteria >4/9 able to touch palms to floor while bending at waist (1 point) genu recurvatum (2 points) elbow hyperextension (2 points) MCP hyperextension (2 points) thumb abduction to the ipsilateral forearm (2 points) Imaging Radiographs recommended views a complete trauma series needed for evaluation (AP-IR, AP-ER, AP-True, Axillary, Scapular Y) findings may be normal in multidirectional instability MRI indications to fully evaluate shoulder anatomy arthrogram needed to assess volume of capsule findings patulous inferior capsule (IGHL anterior and posterior bands) Bankart lesion - may occur in conjunction with traumatic anterior instability Kim lesion - may occur in conjunction with traumatic posterior instability bony erosion of glenoid - following chronic anterior instability Arthroscopy drive-through sign may be present a positive drive-through sign is considered the ability to pass an arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the IGHL also associated with shoulder laxity Differential Diagnosis Unidirectional instability Cervical spine disease Brachial plexitis Thoracic outlet syndrome Treatment Nonoperative dynamic stabilization physical therapy indications first line of treatment vast majority of patients technique 3-6 month regimen needed strengthening of dynamic stabilizers (rotator cuff and periscapular musculature) closed kinetic chain exercises are used early in the rehabilitation process to safely stimulate co-contraction of the scapular and rotator cuff muscles Operative capsular shift / stabilization procedure (open or arthroscopic) indications failure of extensive nonoperative management pain and instability that interferes with ADLs of sports activities contraindications voluntary dislocators capsular reconstruction (allograft) rare, described in refractory cases and patients with collagen disorders Techniques Capsular shift / stabilization procedure (open or arthroscopic) approach arthroscopic approach to shoulder deltopectoral approach for open subscapularis tenotomy versus subscapularis split stabilization must address capsule +/- rotator interval inferior capsular shift (capsule shifted superiorly) plication of redundant capsule in a balanced fashion rotator interval closure (open or arthroscopic) produces the most significant decrease in range of motion in external rotation with the arm at the side address any anterior or posterior labral pathology if present thermal capsulorrhaphy (historical) is contraindicated because of complications including capsular thinning/insufficiency and attenuation, and chondrolysis post-operative rehabilitation 4-6 weeks: shoulder immobilizer or sling 6-10 weeks: ADL's with 45 degree limit on abduction and external rotation 10-16 weeks: gradual range of motion >16 weeks: strengthening >10 months: contact sports patient should resume sports activities only after normal strength and motion have returned Complications Subscapularis deficiency more common after open anterior-inferior capsular shift may be caused by injury or failed repair postop physical exam will show a positive lift-off test and excessive external rotation late finding - humeral head anterior sublaxation on axillary radiograph Loss of motion may be due to asymmetric tightening or overtightening of capsule leads to loss of ER treat with Z-lengthening of subscapularis rare Axillary nerve injury iatrogenic injury with surgery (abduction and ER moves axillary nerve away from glenoid) usually a neuropraxia that can be observed postoperatively can occur with anterior dislocation of shoulder Late arthritis (capsulorraphy induced arthritis) usually wear of posterior glenoid with posterior humeral head subluxation and significant retroversion of the glenoid may have internal rotation contracture (severe lack of external rotation on exam) historically seen with Putti-Platt and Magnuson-Stack (non-anatomic, historical) procedures Recurrence most common complication following arthroscopic or open capsulorraphy high rate following thermal capsulorrhaphy (historical) due to capsular insufficiency open revision indicated (not arthroscopic)
QUESTIONS 1 of 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Previous Next (OBQ05.51) A 20-year-old girl reports a shoulder dislocation while reaching for a high shelf. Her history reveals multiple past dislocations with spontaneous reduction and no obvious traumatic event at onset. A photograph of her hand is shown in figure A. What is the most likely etiology of her shoulder instability? Review Topic QID: 937 FIGURES: A 1 inverted pear glenoid with bone deficiency 3% (60/2385) 2 long thoracic nerve palsy 0% (5/2385) 3 Bankart lesion 2% (43/2385) 4 capsular redundancy 93% (2224/2385) 5 Buford complex 2% (37/2385) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07SM.97) What procedure can eliminate a sulcus sign? Review Topic QID: 8759 1 Rotator interval closure 58% (47/81) 2 SLAP repair 5% (4/81) 3 Bankart repair 22% (18/81) 4 Supraspinatus repair 15% (12/81) 5 Subacromial decompression 0% (0/81) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.150) A 16-year-old swimmer has pain and weakness in her dominant shoulder with overhead use. Her physical examination demonstrates a +2 anterior and posterior load and shift test. There is 1.5cm of sulcus sign evident with the arm at adduction and 30 degrees of external rotation. Her radiographs are normal. What is the most appropriate next step in management? Review Topic QID: 2963 1 Arthroscopic anterior and posterior labral repair 3% (53/1680) 2 Arthroscopic anterior and posterior labral repair with rotator interval closure 5% (82/1680) 3 Home stretching program with emphasis on posterior capsular stretching 6% (109/1680) 4 Dynamic stabilization therapy 84% (1415/1680) 5 Sport specific bracing 1% (9/1680) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.137) Which of the following is true regarding closure of the rotator interval in patients undergoing arthroscopic shoulder stabilization? Review Topic QID: 3188 1 It can lead to recurrent instability 1% (43/3932) 2 It restricts external rotation predominately in the "arm cocking" phase of throwing 27% (1047/3932) 3 It restricts combined flexion and cross-body adduction 2% (92/3932) 4 It restricts external rotation predominately with the arm at 0 degrees of shoulder abduction 63% (2464/3932) 5 It restricts internal rotation predominately with the arm at 90 degrees of shoulder abduction 7% (261/3932) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.69) A freshman collegiate swimmer complains of right shoulder pain after increasing his workout duration and intensity. He denies trauma and admits to popping his shoulders in and out voluntarily since the age of 8. Exam reveals bilateral anterior shoulder apprehension and relocation, positive jerk test, and a 2cm sulcus bilaterally. O’Brien active compression tests are negative bilaterally. Radiographs are normal and MR arthrogram of his right shoulder is shown in Figures A and B. What is the best initial treatment? Review Topic QID: 180 FIGURES: A B 1 Shoulder range of motion program with emphasis on posterior capsular stretching 3% (86/2728) 2 Shoulder arthroscopy with anterior and posterior capsulolabral plication with superior shift 7% (186/2728) 3 Shoulder arthroscopy with thermal capsulorrhaphy and rotator interval closure 1% (34/2728) 4 Shoulder arthroscopy with repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion 7% (184/2728) 5 Rotator cuff and peri-scapular muscular strengthening program 82% (2224/2728) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ12.10) A 19-year-old female presents with bilateral shoulder pain and instability during volleyball practice. She denies any injuries. Physical exam elicits pain when her arm is internally rotated with her shoulder forward flexed to 90 degrees. In the seated position there is a 2cm sulcus present with inferior traction on each arm. Radiographs are unremarkable. Her representative MRI images from her right shoulder are seen in figures A and B, which are identical to her other side. What is the most appropriate initial treatment? Review Topic QID: 4370 FIGURES: A B 1 Physical therapy 89% (4725/5303) 2 Bilateral glenohumeral corticosteriod injections and physical therapy 2% (95/5303) 3 Bilateral subacromial corticosteriod injections and physical therapy 2% (113/5303) 4 Bilateral staged arthroscopic labral repair and capsulorrhaphies 4% (234/5303) 5 Bilateral staged open capsular shifts 2% (84/5303) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ04.51) An 18-year-old high school volleyball player is being treated for multidirectional instability of the right shoulder with a physical therapy program. She has intermittent pain and instability and episodic numbness and weakness in the ipsilateral hand. All of the following are characteristic features of a generalized connective tissue disorder EXCEPT: Review Topic QID: 1381 1 Elbow hyperextension of the left arm 2% (26/1502) 2 Left 5th finger passive extension beyond 90° 3% (51/1502) 3 Genu recurvatum of the bilateral knees 7% (109/1502) 4 Excessive supination of the left forearm 86% (1298/1502) 5 Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand 1% (12/1502) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery Complex Posterior and MDI: All My Tricks - Scott W. Trenhaile, MD (CSMS #9, 2018) Scott Trenhaile Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) 11/11/2018 156 views Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Video Spotlight: Arthroscopic Treatment of Multidirectional Instability - Felix Savoie, III, MD (1.16, 2018 Winter SKS) Felix H. "Buddy" Savoie III Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) 7/9/2018 176 views Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Multidirectional Instability - Does it Exist? - Evan Lederman, MD (1.13, 2018 Winter SKS) Evan Lederman Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) 7/6/2018 242 views See More See Less