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Shoulder Instability For Postgraduate Orthopaedic Exams
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Shoulder Instability For Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
SHWAN HENARI: OK, everybody. Once again, welcome to our FRCS mentor session. We are looking forward to a really good talk on shoulder instability by Mustafa Rashid who's one of the shoulder Fellows in Wrightington. I know every time I hear one of his talks, the topic just becomes that bit more easy and understandable. He, so, without too much delay, we'll introduce Mustafa Rashid.
MUSTAFA RASHID: Thank you, Shwan. Thank you, everyone, for giving up their evening to listen to me. Hopefully this topic, which actually does come up quite regularly in the exam. And I'll explain the cases where it comes up in. And it also came up in my EBOT exam, but this topic in particular, I'm not going to talk too much about it, but there is if there's time at the end, I can talk to you about my experience of what I got in terms of cases for shoulders in the FRCS and how that differed to the case that I got in the EBOT and it couldn't have been further apart and
MUSTAFA RASHID: it really highlights the differences between those two postgraduate exams. So let's see if this works. So OK. So the objectives today, we're going to outline the mechanism of shoulder instability and we're going to recap the associated pathologies and discuss management strategies, surgical and conservative for treating patients with an unstable shoulder.
MUSTAFA RASHID: I'm going to give you three example cases that could easily have come up in the FRCS, and then when there's opportunity, like with all the FRCS mentor sessions to do some VIVA practice at the end. So all of these athletes are experiencing shoulder instability and there's lots of different mechanisms. So quite a common mechanism is a fall onto a forward flex and abducted arm.
MUSTAFA RASHID: You could also fall as the Aussie rules football player on the bottom right, although he is struggling to cycle land directly onto the elbow that's extended and so there's an anterior and a superior directed force on the proximal humerus. And there's a couple of, there's a couple of examples there of patients that clearly have already an unstable shoulder and they do very minimal amount of exertion and it really is a muscle contractor event suddenly that is pulling the shoulder out.
MUSTAFA RASHID: And you can hypothesize that I mean, those patients, they probably had a more significant traumatic event previously and was never fully stable before it came out again. So so there is a variety of ways in which you can dislocate your shoulder, but quite commonly it's a fall, there's an element of external rotation, abduction most commonly. So if you get the scenario where you're basically presented with an acute traumatic event and shoulder pain, you've really got to just focus on the assessment and you've got to be quite quick with progressing through this.
MUSTAFA RASHID: You don't really want to get bogged down with what you're going to do in the emergency department because this is basically what you do as an ST3. It's not really FRCS level. So you want to get through, you want to confirm the dislocation and that's with clinical and radiographic confirmation. You want to assess for neurological and vascular compromise and that is really key.
MUSTAFA RASHID: That's the kind of a pass/fail thing if you don't assess the distal neurology as well as the axillary nerve and always check for a pulse, you'd be surprised, actually, some of the older patients that have a dislocation, how often they get a slightly thready pulse that often isn't picked up by your junior. So that's that. Attempt to save reduction, which is often in the emergency department and confirm the reduction clinically and radiographically and repeat the neurological and vascular assessment.
MUSTAFA RASHID: Nothing too complicated about that. It's what we do every week when we're on call, we get a similar case. With regards to the radiographs people often get really confused. Just keep it very simple you know, just say what you see. If you're not sure, if they give you just one view, just, just take your time,
MUSTAFA RASHID: say what you see. If you're unsure, hedge your bets and say, I'd like some more x-rays and more imaging please. If they give you two orthogonal views on the X ray, just say I'm really sorry, I suspect there may be instability here, but I would, I'm not 100% sure so in my clinical practice I would confirm this with a CT scan, and that's a safe thing to do OK unless it's bond or obvious
MUSTAFA RASHID: a lot of the time it's not and if you're struggling, you can say one step more than that is you can say, well, the patient obviously is having difficulty getting in the right position to get adequate X-rays radiographs. I would ask the radiographer if they're able to do a modified axial view or a velpeau view, which can often reveal that is not sitting in the deeper humeral joint.
MUSTAFA RASHID: Nearly all patients will need a repeat X-ray after you manipulate their shoulder, and most patients will require some sort of cross sectional imaging in the clinic after they've been after they've been treated for their acute event. So you may get x-rays like this, again, these are pretty, pretty obvious, you know, it's a dislocation.
MUSTAFA RASHID: And just remember, the commonest direction is antenter inferior, you know, 95-97% of shoulder instability goes in the anterior inferior direction. OK? And so that's basically what you're looking for, if you're not sure, and you're not that familiar with seeing these. If you're going to guess, it's going to be anterior inferior. OK? But you can see on the left hand view how the posterior humeral head is sat directly perched onto the anterior glenoid rim.
MUSTAFA RASHID: And so you can imagine there's normally some interposing tissue there, there's a labrum, there's capsule, things like that. And so you can see how in the dislocation you've got (a), you know, a huge amount of capsular plastic deformation for the head to be in that position, (b) the labrum has to have taken some sort of injury, whether it's an avulsion or a sort of compression event. Something has got to have happened to the labrum for the bones to be touching like that.
MUSTAFA RASHID: And, and then look at the bones. You know, the bones will have an impact. And in particular on the humeral head, that is literally an impaction fracture that you're seeing there. The humeral head in that view tends to be reasonably spherical and it's clearly not its hourglass shape now due to the impaction of the head on the glenoid rim.
MUSTAFA RASHID: So you may get something like this. This is not the same patient, although the entries do line up quite nicely. These are different patients, but this is a fracture dislocation and people often get really worried about whether you should be reducing this in the emergency department or not. The safest bet is to say not, you know, just to say that in your experience, this needs adequate muscle relaxation and with an intubated patient to avoid the risk of propagating the fracture across the anatomical neck.
MUSTAFA RASHID: And so that would be a reasonably safe FRCS answer. They will often push you in that scenario to say, well, you know, theaters have just started a 12 hour laparotomy and there's nothing, no one available, in which case, you can then escalate, discuss with your emergency physician colleagues and see if they have the expertise and ability to perform procedural sedation safely in the recuss and if they can't, then it's not unreasonable to say I'll be picking up the phone to my local trauma center because of the unusual circumstances that I find myself in without capacity to be able to do this safely.
MUSTAFA RASHID: I mean that. Yeah, you could say that but you try and defuse the situation and just make it abundantly clear that what you're trying to do is get this reduced because it's an emergency without causing further harm. But in reality, these patients with this kind of fracture dislocation, unless they're reasonably old and frail or unless the greater tuberosity sits exactly where it should be, a lot of the time this will require some sort of surgical intervention anyway
MUSTAFA RASHID: so bear that in mind. You may get x-rays like this and at first glance, this may be quite difficult to interpret, but let's just go through one by one. So on the far left, the proximal humerus on an AP projection is not meant to be perfectly spherical. OK? There's an eccentricity to the humeral head in relation to the anatomical axis of the humerus. And so if you're seeing a humeral head that sits perfectly in line with the humeral shaft, then if you were to draw a line straight down the humeral shaft, not sure if you can see my cursor if you go straight down here and 50% of the head is on either side, this is a posterior dislocation until proven otherwise.
MUSTAFA RASHID: OK this is the infamous light bulb sign because the humeral head looks like a light bulb and it's not meant to. This is also something similar. OK? There's something not quite right here. OK? You can't quite make out where the glenohumeral joint is. There's significant overlap and there's also some sclerosis within the head. Right so this is also a similar sign.
MUSTAFA RASHID: This is the trough sign and this is the loss of half would overlap sign. And then finally, the modified axial tells you the story here. This is the glenoid, yeah, relatively flat socket. This is the humeral shaft, this is the humeral head and we can see as you trace the glenoid is the anterior er sorry posterior glenoid neck and the humeral head is sat within it and
MUSTAFA RASHID: in fact, it's compressed. About a quarter humeral is missing here. And that's because of a significant impaction fracture to the posterior glenoid rib. So all in all, all of these radiographs they're of different patients, but they all describe posterior dislocation, which is, I would put it in the category of a classic FRCS VIVA's scenario, trauma VIVA's scenario, because they can take it a lot different ways.
MUSTAFA RASHID: They can write the same branch question with the same radiographs and take it you know, five or six different routes so it's a really high yield question that comes up in part two. You often get a starter like this after you've identified what it is, they'll say, what are the signs of posterior shoulders dislocation? And most people get really bogged down with the radiographic signs.
MUSTAFA RASHID: They remember light bulb sign and they go a light bulb sign. And then the examiner goes one of the other ones, and then they're just blank, so be systematic like I've talked about in my previous talks, the signs are clinical or radiographic. The clinical signs are loss of external or passive external rotation. The radiographic signs include the light bulb sign, the trough line sign, which is basically a reverse Hill-Sachs impaction fracture
MUSTAFA RASHID: so it looks like a stripe of sclerosis within the medial humeral head. There's the loss of normal half moon overlap and then there's the Rim sign which wasn't really visible on those X-rays prior, but the rim sign is essentially a vacant glenoid fossa, so it looks like a widening and the definition in some radiology text textbooks I believe is more than six millimeters, but it just looks abnormal
MUSTAFA RASHID: so just have a low index of suspicion. You're shown an X-ray of someone and the history is some sort of traumatic, minor traumatic event, and now they're struggling with pain or loss of external rotation. Just think, could this be a missed posterior dislocation? And then lastly so rotations the clinical side, really?
MUSTAFA RASHID: You often will get asked about nerve injuries, you know, you may say, well, I was, I would evaluate the distal neurology median, ulnar radial nerves, as well as the proximal neurology auxiliary nerve, so we look for any signs of deficit and then you may get asked, well, what is the commonest nerve injury you expect with a dislocation?
MUSTAFA RASHID: And the answer here, based on this paper from Holland, is the auxiliary nerve. It's most commonly affected. And what they actually found which is really quite interesting is the rate of neurological injury, where the dislocation episode is strongly correlated to the age of the patient. So the older we are, the more likely it is that you'll have a nerve injury. And they actually did a study where they gave everyone an EMG to quantify this, and they found nearly half had some degree of external loss, the vast majority of which will recover spontaneously with observation.
MUSTAFA RASHID: But we've really got to be aware of it and I've seen quite a few patients in their 70s who've got a infraclavicular brachial plexus, dense brachial plexus palsy that's taken a very long time to show signs of improvement. In the clinic, it's a different scenario, OK? It's you're in the fracture clinic or the elective shoulder clinic and you're presented with a case.
MUSTAFA RASHID: Keep it very simple. Take a history. What's the mechanism? Is it a first time dislocation? Do they have pain currently? Are they a hypermobile patient? When they had their dislocation recently, did they need reduction? That's really quite important.
MUSTAFA RASHID: Shoulder surgeons really obsess about this because the patients come in and go and you ask them, how many times have you dislocated? Oh, 17 times. And you're like OK and you look at their patch record, they've never been to any other hospital and they've only got 3x rays. So there's something not quite right. They're probably having instability episodes where they may not be having frank dislocation episodes that require sedation and clinical input to reduce it.
MUSTAFA RASHID: And that doesn't necessarily mean that it's not relevant that they're having these several episodes. It just means that either they're so unstable the patient has learnt how to reduce it spontaneously or more likely they're perching and coming back to the center of the glenoid fossa. So that's quite important. With your examination, again, look, feel, move, special test.
MUSTAFA RASHID: The same thing that we learnt when we were junior registrars. In special tests, don't forget apprehension. I always do my apprehension supine. You can do it standing up, but supine is usually preferred and remember, there's a few little tricks for this, but you just got to instill confidence in the patient and take it very slow. So what I often tell the patient, I get them to lie down,
MUSTAFA RASHID: I ask them to bring their arm out to the side with the arm entirely rotated. So like this much, imagine they're lying down. I then put my elbow sorry my hand behind their elbow and I ask them, imagine my hand is like a coffee table. Rest your arm, rest your elbow onto my hand and then I say to them, let gravity bring your hand down. So I'm like letting them relax and allowing passive external rotation with the assistance of gravity.
MUSTAFA RASHID: Now once you get to around 70 degrees axial rotation plus, you'll find the patient feels uncomfortable and they'll never tell you I feel like I'm getting this pain. Patients do, but often I'll say to them, does that feel weird? Does that feel uncomfortable? Does that feel like it's not sitting in the joint properly? Does that feel like it might come out? And they often say yes.
MUSTAFA RASHID: In which case you then apply a posteriorly directed force to the proximal humerus and you keep it there. And you say to the patient, does that get rid of that uncomfortable sensation? And if they say, yes, that's apprehension, positive, and Jobe's relocation test positive and often you can do rebound test. So you let go of that post aggressive force and they will get apprehensive again.
MUSTAFA RASHID: But that's a bit mean. But I would say that the key one for me is when I recenter the humeral head in abduction external rotation, I push back with a reset of the humeral head, it then relieves that proprioceptive stretch on the anterior inferior capsule, and they feel like that's where the humeral head is meant to sit. And so that apprehension sensation goes away
MUSTAFA RASHID: and that is really quite a sensitive sign. In older patients, always assess cuff integrity so resisted abduction into rotation, resisted external rotation, and some sub sat tests, whichever you like and again, always talk about neurovascular status, but don't talk about it like that, split it up into median, ulnar and radial and axillary nerves. When it comes to your imaging in the clinic, start with radiographs.
MUSTAFA RASHID: There are some special views you can get to identify a Hill-Sachs lesion and a glenoid rim fracture. Don't worry too much about that. Just ask. At the very least, an AP and an axial. And then there is some debate about what form of cross-sectional imaging you get. In common practice, It's MRI in some centers, it's an MR arthrogram.
MUSTAFA RASHID: And the radiologists debate about this quite a bit, I mean, the literature is actually quite clear. The MR arthrogram is more sensitive to picking up capsule labral injuries, but often there's logistical issues with getting those in numbers. There's limitations and MSK radiologists are unable to do the arthrogram, you know, that takes time and availability is the biggest issue. And some people now argue if you have a three test, plain MRI, it's just as good, which is probably true.
MUSTAFA RASHID: But you know, the gold standard is the MR arthrogram. The examiner may ask you, well, if they had an acute injury and you have access to a scan within a week or two, do you need the arthrogram? And what they're basically getting at is for you to understand that the hematoma caused by the injury acts like a contrast, and a plain MR may actually be sensitive enough to pick that up.
MUSTAFA RASHID: Ultrasound scan is probably the mainstay for the over 40-year-old patient with an instability episode because it's the most easily accessible way of assessing the integrity of the rotator cuff. And most shoulder surgeons believe that an acute traumatic rotator cuff tear picked up early should be treated early with an operation. And that has been challenged by a Swedish study relatively recently.
MUSTAFA RASHID: But that's still the prevailing sentiment within the shoulder community. So if you get a person over the age of 40 who's had a dislocation, so get an urgent ultrasound if there's a full fitness rotator cuff to get them into theater. And in some places they even go onto the trauma list for the shoulder surgeons to do an acute cuff repair. But in most places they probably get listed as a PE two semi elective acute case on the elective shoulder list.
MUSTAFA RASHID: In some places they get a CT or a CT arthrogram. I worked at one place where that was their mainstay investigation. It's very common in continental Europe and France in particular. And I can see the logic for this as well. I think it probably it might be my preference as well as a consultant, because if you have a young person with a traumatic anterior dislocation, you almost certainly can bank on the fact that they'll have some sort of anterior inferior capsule labral injury of some variety.
MUSTAFA RASHID: And in reality, if they're going to proceed to require surgical stabilization, you will see that with arthroscopy. One thing that does change your decision making process is if they've got bone loss and people argue to death about how accurate MRI is versus a CT scan, but CT scan still remains the gold standard for assessing bone loss. And so if you were to have one cross-sectional imaging investigation that will profoundly determine how you manage the patient, I would argue that a CT is probably it because that's the most accurate way of determining whether there's bone loss.
MUSTAFA RASHID: And bone loss is what really determines whether the patient will have a soft tissue procedure or not. It's just something to think about. The safe answer is an arthrogram if available? Plain MR if the consultant radiologist feel's that that is probably accurate to pick up capsule labral pathology. That's the safe answer. Also the clincher, just be wary of this.
MUSTAFA RASHID: Right so if you have a look very carefully, this is a young man who's had an instability episode and he's got some abnormal scapular movements here. He's getting early retraction and some flexion are prominent in for a medial angle of his scapula. This is very common and a lot of this can be rehabilitated. But patients often won't tell you oh it feels weird on my scapula. They'll just say, my shoulder hurts easier because you've lost the normal proprioceptive pathways, of which the anterior inferior capsule labral junction provides a significant contribution to.
MUSTAFA RASHID: So I think my mic might have cut out then so I'll just repeat that. If you see some sort of scapular asymmetry on clinical examination in someone who's had a relatively recent instability episode, that is probably the fact that they've got a capsular labral injury and loss of the normal proprioceptive mechanisms to ensure that they know where their scapula is positioned in relation to the glenohumeral joint. And so this is quite a common thing that often will rehabilitate back to normal but often won't
MUSTAFA RASHID: and so you've got to look for it as well. No talk on shoulder stability is complete without mentioning Arthur Bankart. He was a London based surgeon in the 20s to 50s he's a bit of a legend, really, in shoulder surgery and he was really quite annoyed at his time in the 20s and 30s when there were over 100 operations prescribed for doing various things to the shoulder to stabilize it.
MUSTAFA RASHID: And his view was that everyone was just not seeing the lesion, they were not seeing the pathology. And so he advocated taking down the coracoid, which no one really does nowadays, but taking down the coracoid to fully expose the anterior inferior labrum and the capsule and the glenoid rim. And then he says, you will find the essential lesion is what he described, which is this anterior inferior capsular labral avulsion from the glenoid.
MUSTAFA RASHID: And he actually called it the bigger glenoid ligament and he actually thought the labrum often didn't heal very often so he would excise the labrum and attach the capsule using dental drills and catgut sutures directly onto the glenoid face and that was his technique and then he would wire the coracoid process back on. But the Bankart lesion is an anterior labral detachment. And the thing to say about the labrum, this is an important point, is the labrum is dense in proprioceptive nerve fibers.
MUSTAFA RASHID: It also really is a conduit, so the capsule in the inferior glenohumeral ligament to attach to the glenoid bone. And that's really what the labrum does. And so if it's detached, it's not really a bumper you know, look at how flat the glenoid fossa is and look at how much it's deepened by the labrum, this is not enough to stop this giant humeral head from dislocating, right? So it's not really a bumper,
MUSTAFA RASHID: that's just rubbish. It looks like a bumper, but in reality that's not how it functions. It's predominantly a proprioceptive structure and so it allows your brain to know where the center of the glenoid fossa is in all positions of putting your arm in space. And it also allows the static check raise of the capsule in the inferior glenohumeral ligament in particular to attach the glenoid and be functional.
MUSTAFA RASHID: There are a number of other associated pathologies, some of which are described here. This is a very famous Google image which I'm not actually sure where it comes from. I've seen this in so many slides and then the MRI slice sequence, the coronal scan that we see there is demonstrating a Hagel lesion, which is a glenohumeral ligament avulsion from the humerus.
MUSTAFA RASHID: So not from the glenoid but from the humeral side. My advice to you about the associated pathology, if you get asked the question about this, is just keep it simple. So just say, OK, the Bankart cartilage is the essential lesion. So that's the thing that you're most likely going to have in a traumatic anterior shoulder dislocation. Or you may have that plus some bone which would make it a bony Bankart or some periosteum, which could be a Perthes lesion
MUSTAFA RASHID: and if it's stuck down medially it's a ALPSA lesion or cartilage, which is a GLAD lesion, it doesn't really matter what they're called, just don't get too bogged down with that. But each of these is a slight variation on a theme. It's the anterior inferior glenoid rim plus capsule plus bone issue. And then the capsule itself can have detachment, as we've said, either from the glenoid, which by definition is what a Bankart lesion is.
MUSTAFA RASHID: It's the capsule attachment to the labrum, which is no longer attached to the headline rim or more commonly it's often missed is a detachment from the humerus. If you ever see a Hagl lesion, these patients are profoundly unstable in clinic. They really don't, their shoulder is terribly floppy. It sits within a very capacious volumous bag now within the capsule, because there's nothing really attached.
MUSTAFA RASHID: So be aware of those patients. They often will be apprehensive, even at low levels of abduction. You may get shown a radiograph like this and they'll say, what do you think? And you can say that the glenohumeral joint is endlocated here, but we can see a significant impaction compression fracture of the posterior humeral head in keeping with a Hills Sachs lesion.
MUSTAFA RASHID: So Hill Sachs, two people, both radiologists, both American Harold Hill and Maurice Sachs, they actually didn't describe the lesion. They just popularized it. It was described many years earlier by someone called Eve. Soon after, the discovery of x-rays by Wilhelm Roentgen, who I think had his anniversary of the discovery not so long ago, maybe last week, but they really popularized it and said that you know, we should be looking for this.
MUSTAFA RASHID: They were both radiologists. Then various surgeons came along in the Nougties and described this concept of the engaging Hill Sachs lesion, which came and went very quickly, actually, once people realize that every Hill-Sachs lesion engaged at some point in its lifetime, right, but what they were really talking about and this is really Steve Burkhardt's work from San Antonio, Texas, is, he described at the time arthroscopy, bringing the arm up into abduction, instead of rotation to see if he could get the impaction divot fracture of the Hill Sachs lesion to actually perch onto the glenoid rim.
MUSTAFA RASHID: And this is what that looks like. You can see this is quite a bad shoulder. The thing that you're looking at on the right is the humeral head. Let me just see if I can play this again. And you can see that's a very large and very wide Hill-Sachs lesion and you can see how as the arm gets externally rotated, this can quite easily engage onto the anterior glenoid rim.
MUSTAFA RASHID: Bony Bankart we talked about. These most commonly will require surgery. you know, think of it as an articular fracture., you know, this should be treated as such. When these are missed, it's often quite difficult. I mean, the patient has a miserable time, they go down the elective pathway, which in the current climate of COVID in the NHS is often taking months to get to a surgical, definitive resolution.
MUSTAFA RASHID: And so this is very unstable, especially if it's displaced, especially with a significant portion of the glenoid rim and so this is not a very pleasant thing to have to live with and go back to work with whilst you're waiting your elective operation. They often need a CT to better assess them. A lot of the time, we've picked these up late.
MUSTAFA RASHID: The fragment is displaced, medially, and then stuck down to the glenoid neck and that's quite a shame and if that's a significant portion of the glenoid rim, then really any soft tissue procedure, any acute surgery to try and heal the fracture in the correct position is lost then at that point and so then you have to do something to replace the bone that's lost.
MUSTAFA RASHID: We briefly talked about what imaging - there's a nice paper that looked at this. Lots of different studies have looked at it, lots of narrative reviews but essentially the consensus is thought to be that three Tesla scanners are better than 1.5. Tesla scanners for picking up capsule labral pathology. In North America, it's very popular to do this ABER position this abduction external rotation position in the scanner, which is thought to be quite beneficial for improving the sensitivity of imaging.
MUSTAFA RASHID: We do it in variable amounts in this country I would say, in the places I've worked. They concluded that MR arthrogram is much 96 was 93% better for picking up labral lesions, but in terms of detached labral fragments, it was highly, significantly more sensitive and that's purely because you've got the contrast going around that fragment on the arthogram, which you don't have in the MR.
MUSTAFA RASHID: And then the important thing to know is that you can miss lesions with the MR, it's not infallible, but it is, it is slightly more sensitive, even though it can be quite challenging to organize that in your setup. So try to think of the associated injuries, a bit like a ladder of ascending things that make you more and more unstable and more likely to push you towards surgical intervention.
MUSTAFA RASHID: So you've got your Bankart lesion, which everyone pretty much gets. You've got your Hill Sachs lesion, which again, most people get for varying degrees. You get large Hill-Sachs lesions, you get small Hill-Sachs lesions and we'll talk a bit more about that later. You can get your ALPSA lesions, your GLAD lesion, Perthes lesion, all these other extensive periosteal sleeve avulsions or cartilage plus periosteal sleeve
MUSTAFA RASHID: avulsions that you get, they will make you generally more unstable. A Bony Bankart, by definition, you've lost bone from an area of the body that is notorious for not being a large socket, large bit of bone, and that makes you significantly more unstable, and then as we talked about earlier, the top thing is if you have the Bony Bankart, a large capsular avulsion from the humeral side and the Hill Sachs lesion, that patient is going to be profoundly unstable,
MUSTAFA RASHID: so think of it like a ladder of ascending associated pathologies. You may get asked about how you classify instability. Lots of different ways to do this. In the UK. I guess the standard, because it came from Ian Bailey and the Stanmore group many years ago now is probably the Stanmore triangle. You should probably know about this for the exam. Essentially, the Stanmore triangle is three polar types and you need to appreciate that patients don't have to sit on the corners of this triangle,
MUSTAFA RASHID: they often rarely do, actually. They'll have contributions from all three polar types. And the important thing to note is that there are temporal changes and patients can move within the triangle depending on rehab, the time since injury, et cetera. And so now, you, Anju Jaggi, who's the Senior Physiotherapy Consultant at Stanmore, talks about the Stanmore prism as the patient moves through within that triangle through time.
MUSTAFA RASHID: But generally speaking, your acute young recreational sporting traumatic anterior instability is likely to be most commonly a polar type 1 injury. But you need to be aware that there are polar type 2 injuries, and these are patients that are hypermobile that may have a traumatic event but often don't, or the trauma is very minor, not really significant enough to warrant association with possible labral injury.
MUSTAFA RASHID: They often won't have a Hill-Sachs lesion on the X-ray, that's a big giveaway for these patients, you do an MRI, you might see some chronic changes in the labrum; doesn't look detached, but there's no Hill-Sachs lesion and that's because they're so hypermobile, they don't, there's never enough constriction within the soft tissues for that impaction fracture to occur as they sub blocked or dislocate.
MUSTAFA RASHID: And then you get the type threes, which a lot of us have come across in on calls in A&E. They tend to be quite young, they tend to have a variety of issues, they come in very regularly to the emergency department with a dislocated shoulder, and these are a complex group of patients to treat, and they almost certainly do not require an operation. Same with the polar type twos,
MUSTAFA RASHID: they rarely need an operation unless there is a significant traumatic event that creates a structural lesion and someone who was previously quite hypermobile and even then it can be very difficult to treat them surgically. The vast majority mainstay of treatment for type twos and 3's is physiotherapy. Type one is often surgery, but we'll come on to that. You may get asked about risk of recurrence, and you really do need to know this paper, one of the many landmark papers by Mike Robinson in Edinburgh.
MUSTAFA RASHID: I mean his work is truly quite amazing and this is a good example of that. This is a study looking at the two year recurrence rate following a first time shoulder dislocation. And what he basically found, he kind of built on the work of a chap called Leonard Hevelius, who worked in like The Mayo in Sweden, which is really Northern Sweden, Arctic Circle, who wrote a bunch of papers in the 90s and early noughties looking at long term follow up of shoulder dislocations,
MUSTAFA RASHID: and what he basically found was your lifetime risk of recurrence is directly linked to your age of first dislocation. And Mark Robinson did this in a very elegant way in Edinburgh, where he looked at the two year recurrence rate and found the same thing. And he gave us these nice relative risk ratios of recurrence after first dislocation based on age. But he also demonstrated that if you are male, that was also a significant risk factor for recurrence.
MUSTAFA RASHID: So you can see that the two year recurrence rate is actually significantly different between men and women. So this is quite a useful thing to think about. The way I tend to remember it is at the age of 27, you've got a 50% chance as a bloke to have another dislocation if we did nothing within two years. And similarly, if you, a very young female, 16, 17, 50% risk, that's one way to remember it.
MUSTAFA RASHID: The other way I remember it as if you're under 20, you've got an over 75% chance of having a two year recurrence if your dislocation was at that age. So you need to know this, that's quite key for FRCS. And don't worry too much about this, but people have tried to quantify your risk of failure following an arthroscopic Bankart repair, and this group in Nice: Pascal Boileau, a very famous shoulder surgeon who described the ISIS score before ISIS, the other group.
MUSTAFA RASHID: And he basically said, if you've got more than six points, that correlates to a 70% recurrence risk and a mean of 31 months. But this kind of study based on retrospective data is probably not the thing that you really want to be quoting for your to hang your hat on in terms of decision making. But what it did do is kind of quantify to some degree the risk factors for recurrence following a soft tissue procedure, so you can see them here on the left.
MUSTAFA RASHID: If you're very young, if you're playing competitive sport, if you're playing contact sport, if you're hyper lax, if you've got a large Hill-Sachs lesion, and if you've lost some bone on the glenoid side, these are all risk factors that he thought increase your risk of failure with a Bankart repair. And interestingly now Pascal Boileau is very famously to have said that all of his patients, regardless of amount of bone loss, will get an arthroscopic Latter-Jet procedure,
MUSTAFA RASHID: so he didn't do any Bankart surgery, which is definitely not a view that you want to trot out in the FRCS because that's not the common UK practice currently. This is a video of a surgeon that I went to visit in Colorado called Peter Millett doing a Bankart repair. I'm just going to let this run, I won't let it run all the way through but it's really nice for those that haven't seen much arthroscopic shoulder surgery to understand what's going on here.
MUSTAFA RASHID: So we're viewing from the posterior portal. This is the left shoulder, this is the probe coming in and you can see it, the probe just falls down in between the labrum and the glenoid rim. You can see this is quite an acute scenario. This is in America where you can see a lot of hemorrhage so this patient would have dislocated not so long ago and you can see there's quite a capacious, inferior recess, the IGHL is d tension.
MUSTAFA RASHID: That inferior sling is not tight at all and what you'll see here, he'll debride some of the frayed tissue and start to mobilize the labrum. As you can see here, he's going to bring in oh, he's going to show you the Hill-Sachs lesion there very quickly, we'll come back to that in a moment. He's testing the superior labrum to see if there's any extension superiorly of this labrum detachment. Here's the Hill-Sachs lesion again.
MUSTAFA RASHID: This is quite a deep but narrow hills occlusion. And so he's dividing some of the frayed tissue here with a soft tissue shaver, and that's using a periosteum elevated arthroscopic lead to really elevate the labrum and the attached capsule to it. He then is making his anterior portal and using a hook probe here to
MUSTAFA RASHID: release the tissues from further. It's often quite a useful step because then you can see how mobile now the labrum of the capsule is to be able to re-tention it onto the glenoid rim and then he's basically going to prepare the glenoid, pass some anchors and re-tention the glenoid rim. I'm just going to see if I can show you the final construct, what this looks like.
MUSTAFA RASHID: So you can see here, you can see here that the bumper, if you like, has been reconstituted. That's not really what's important, the important thing is you reattach the capsule via the labrum onto the glenoid rim. So now once that's healed, you've restored your proprioceptive feedback mechanism
MUSTAFA RASHID: so that you now know where the anterior glenoid rim is, so you can keep the head centered using your important dynamic stabilizers of the shoulder. OK. There is a Cochrane review on this topic. It basically concluded that primary surgery in young men with highly demanding sporting and physical activities after the first dislocation is, is probably warranted. But there's no evidence of which type of surgery is the best, and that's probably fair to say.
MUSTAFA RASHID: It's important for you to mention this in the FRCS. Yes this is the best guidelines. There's a few pathways. There's one for traumatic anterior, there's one for a-traumatic and there is one for multi-directional instability, which we're not going to talk about. But they came out with this suggested algorithm for treatment. If you're under 25, you should be referred to a shoulder specialist for secondary care
MUSTAFA RASHID: You should be allowed to mobilize as soon as the pain allows. You should be assessed by a shoulder surgeon within six weeks and have some imaging and consideration of arthroscopic anatomic repair. If you're 25 to 40, you should be reassessed at 3 to six months in the shoulder clinic and if you remain symptomatic, have the same diagnostic imaging and treatment.
MUSTAFA RASHID: If you're over 40, you should be assessed early in terms of diagnostic imaging and shoulder specialist and have an early rotator cuff repair if clinically relevant, that's not always the case. and if you're 90 years old, it's OK. The chance of you having a cuff, cuff tear before you dislocate it is incredibly high and so you're not going to start repairing all those 90-year-old cuff tears.
MUSTAFA RASHID: But if you're 45, previously normal shoulder and dislocate, you've got a full thickness cuff lesion, then they advocate you should probably be repairing those early. So you can always fall back on the best guidelines, they're not particularly well evidence based because there isn't a great evidence base for this, but that's what UK practice tends to be in this country. And you won't get asked about this, I don't think but if you get a Hill-Sachs lesion at the time of a Bankart repair, some surgeons advocate doing something called a remplissage, which is a French word that means to fill in.
MUSTAFA RASHID: You're filling in the defect by putting the capsule and the infraspinatus tendon into that defect and I'm filling it in so that as the patient externally rotates and abducts, this defect is now filled with soft tissue and cannot engage onto the glenoid rim. That's a remplissage. Some surgeons like it, a lot of surgeons don't use it. You do need to know about Laterjet.
MUSTAFA RASHID: Laterjet is essentially a corocoid transfer operation for, in this country, predominantly glenoid bone loss. And so you basically take the coracoid with the conjoined tendon attached to it off. You make a split into the subscapularis and you attach it usually with two screws into the glenoid. And you basically, when you've got a flattened anterior glenoid surface and you've lost bone, the glamma is meant to be pear shaped,
MUSTAFA RASHID: If it's not pear shaped, you haven't got much of a socket for your head to stay on and therefore you're widening the socket and you're increasing the distance required to jump the bone to dislocate. That's the primary, that's one mechanism for keeping this and making it stable. The other mechanism is, as you can imagine, as you abduct and externally rotate your arm, the conjoined tendon then creates an inferior sling or hammock and adding a dynamic soft tissue constraint to dislocation.
MUSTAFA RASHID: And so those are the two primary mechanisms for a Laterjet. And if you'd really getting on to an eight, you may be asked to talk about the variations of a Laterjet. So this is the traditional Laterjet, this is what's called the congruent art technique developed by Joe de Beer and Steve Burkhardt in 2004. And they basically just rotated the coracoid 90 degrees and fired the screw through the thin axis of the coracoid, which is a little bit more unforgiving.
MUSTAFA RASHID: It's about 4 millimeters versus 7 millimeters. But the benefit of this is the angle perfectly matches the curvature of the glenoid fossa and it also increases your graft width. So that's called a congruent art technique. The surgeon that I work for at Wrightington - Professor Len Funk; this is his preferred technique. And he treats a lot of professional rugby players with Laterjet using this technique
MUSTAFA RASHID: so it is very effective and powerful. The alternative is a bone block procedure where you're taking either iliac crest, distal clavicular or allograft and you're bolting it on to the front of the glenoid to reconstitute the missing bone from the glenoid side. It's technically more anatomic, if you like, because it's not you're not transferring anything from anywhere else,
MUSTAFA RASHID: you're addressing glenoid bone loss. The problem is this is dead bit of bone that you're asking to heal to something that isn't particularly well vascularized. And if it doesn't heal, and resorbs and that's a problem, because then you've got hardware, you've got metal screws that are prominent in the shoulder. But you can do arthroscopy or open,
MUSTAFA RASHID: you can do it with a variety of different auto or allografts. This is often described as an Eden-Hybinette procedure named after the Swiss surgeon who perscribed it. So just like we talked about with associated pathologies, there's also a surgical ladder for stabilization. Conservative management. Arthroscopic Bankart repair, plus or minus remplissage. An open Bankart repair, you could argue, although it's not very commonly done anymore,
MUSTAFA RASHID: I would argue it's a very powerful way to stabilize a shoulder because it allows you to reattach the capsular labral tissue, but it also allows you to address capsular redundancy by double breasting the capsule ostomy that you make. So most people will do a t-shape capsulotomy and you can bring the two leaves over each other and reduce that capsular redundancy. Then there's bone block procedures, a Laterjet procedure, and then you can get into the weirder, wonderful art commonly done in this country,
MUSTAFA RASHID: but they are in North America, which is a distal tibial allograft. If you get a dislocation case in someone who's over 40 years old always, always think about the rotator cuff, forget the labrum, that's not important in this age group as much as the rotator cuff. Rotator cuff will determine the outcome of the patient
MUSTAFA RASHID: and also the rehab. So if you get someone who dislocates after the age of 40, just think about the rotator cuff. And get some early imaging within two to three weeks to assess for a cuff tear. And if you do see it, you will see it in 35 to 86% based on the literature, the cuff tear guides the management and rehab for that patient. You know, there's debate about whether you address the labrum at the same time of doing the cuff repair,
MUSTAFA RASHID: A lot of the surgeons don't bother because if you had a 40-year-old who didn't have a cuff tear when it dislocated and just had a labral lesion like a Bankart lesion, the risk of recurrence at the age of 40 plus is very low so you wouldn't ever offer them surgery. So a lot of surgeons are more than happy to ignore that and just treat the cuff tear acutely. And I think that's right.
MUSTAFA RASHID: Just one slide on posterior instability, it doesn't come up that much in itself other than in one very specific scenario, which we'll come on to. It's very easy to miss. Look for the subtle signs and the lack of passive external rotation. Posterior apprehension test is not as useful, you got taught that in medical school and as I say, it's just not as useful for posterior stability but pain posteriorly,
MUSTAFA RASHID: There's very few things that patients describe pain at the back of their shoulder, in their joint line. But one of them is often a posterior labral injury. And that's often worse if you get them in this position and to resist elevation, that makes it worse because they're basically trying to stabilize the humoral joint and they don't know where the back is so their dynamic stabilizers are firing, but they're not centering the humeral head
MUSTAFA RASHID: and so that pain often gets worse because they're pushing onto that posterior and capsule labrum. And most do not require surgery unless they're quite high level athletes or feel very unstable as well as painful. So the FRCS case that you tend to get, you get your bog standard traumatic anterior instability because there's lots of nuance, right?
MUSTAFA RASHID: You can vary the age, the gender, whether they play contact sports and you can have a discussion about all the associated pathologies. So that could come up. You don't tend to get the atraumatic MDI multidirectional disability type III muscle pattern or type instability, that's probably a bit unfair to get that. You do quite commonly get fracture dislocations. So approximately you haven't really talked about or displaced gd fractures.
MUSTAFA RASHID: And the one thing that I talked about earlier, which we'll come on to is you do very commonly get the locked posterior dislocation, often in a slightly older patient. So let's go through the cases, shall we actually just take a 2 minute break to take questions? Shwan, do you have any questions at all there?
SHWAN HENARI: Yes sorry.
SHWAN HENARI: There are a couple of questions. The first question is actually from on rotator cuff's sorry, on track versus off track lesions. Could you please explain that again?
MUSTAFA RASHID: I haven't talked about that yet, but I will talk about that at the end. I've got some bonus slides if you really want to learn about on track. Off track, you won't get to in the phrases unless you're doing exceptionally well.
MUSTAFA RASHID: I did get asked it in the exam, but then again it's a shoulder session asking me and I'm a shoulder I'm a shoulder surgeon. So we got quite deep into that case. But I will talk about on track, off track at the end of the talk, I promise, if we've got time.
SHWAN HENARI: I think the question for me in the FRCS is if you have a first time dislocation or would you and you can't see any obvious abnormality on the X ray?
SHWAN HENARI: Would you say you would go for a CT scan to look for a Bony Bankart or would you wait?
MUSTAFA RASHID: And now they all get cross-sectional imaging so wherever that is of your choice, I would say the safe answer is probably an MRI first, because you will pick up a Bony Bankart with an MRI a lot of the time, it's just quantifying the amount of bone loss is not as accurate in MRI, but the answer to that is they're seen in the shoulder, upper limb trauma clinic within a couple of weeks,
MUSTAFA RASHID: the advice is to discard the sling as soon as the pain subsides. No restriction in mobilization, and they get cross-sectional imaging of whatever your preference is, most commonly an MRI to look for the associated pathology. And if they're under 25, they get offered surgery if their clinical features are in keeping with their radiographic findings and if they are over 25, you can try physiotherapy and reassess.
MUSTAFA RASHID: And the risk factors for pushing more towards surgical management after a first time dislocator are age, gender and contact sport.
SHWAN HENARI: So in the exam you would answer it in the way of younger patients you're more likely to offer surgical.
MUSTAFA RASHID: Yeah so, Yeah. So I would just play it safe and just say there are very good best guidelines on how to manage traumatic and serious stability.
MUSTAFA RASHID: That's what I would follow, which involves clinical and radiological assessment via cross sectional imaging in a specialist shoulder clinic with offering arthroscopic soft tissue stabilization if that's the primary lesion in young people under 25 the first time dislocator, that's what the national recommendations are and that's what most people's practice is, to be honest with you. That gone are the days of, oh, you've had only one dislocation,
MUSTAFA RASHID: well, go away and come back when you've had your second and then we'll stabilize you. Those days are gone. The only time you do that is in slightly older patients or patients that aren't particularly active they've just had a freak traumatic event, that's why they're dislocated.
SHWAN HENARI: OK, perfect answer. Thank you very much. If there's no other questions, we can move on.
MUSTAFA RASHID: Yeah, I think. Mehwali, did you ask about the radiographic signs or are you happy with that? I think we'll come back to that. So this is case one: It's a 21-year-old fit and active manual labourer who fell off a bicycle, he's now in the emergency department and he's got left shoulder pain
MUSTAFA RASHID: so this is quite common. This is the clinical radiograph you may get shown, this is just taken off Google. This is a very common picture, you see this a lot. Just take your time and just say what you see what you see. I'm not sure if you see my mouse here. Whenever you see this squaring off of the shoulder, just look at the opposite side,
MUSTAFA RASHID: that's what your normal shoulder contours are meant to look like. The most lateral part of a normal shoulder is your humeral head, your great tuberosity and the deltoid muscle. When you've dislocated anterior inferiorly, the most lateral part of your shoulder now becomes the lateral edge of the acromion and that's very visible here. Yeah so whenever you see that, it's almost certainly going to be an anterior dislocation.
MUSTAFA RASHID: OK so then you may go through your spiel of immediate assessment and get radiographs to confirm and you may get shown something like this. Don't get bogged down too much with this. This is an AP radiograph demonstrating the anterior dislocation of the glenohumeral joint with what looks like a Hill-Sachs lesion. I would then transfer the patient to the resuss department, request immediate procedural sedation and safely reduce the shoulder documenting neurovascular status before and after.
MUSTAFA RASHID: And then confirming the same radiological events and joint. Very simple, nothing too difficult about that. The top tips for this kind of case, try to progress quickly through the A&E management, you really want to get to talking about the pathology on imaging and how you're going to manage this patient in the clinic and the nuances of age, gender, time of dislocation, recurrence, all of that is where you really want to get to with this stage as quickly as you can.
MUSTAFA RASHID: The station can take many different routes. They could start off the same way and you and your friends may get different questions. It may focus on how you reduce it in A&E, it doesn't really matter how you do it you've just got to be able to describe how you do it and why it's and why you choose to do that and how you go about doing it. It may talk about a nerve injury, either pre or post reduction, and how are you going to manage that?
MUSTAFA RASHID: Again, keep it very simple. You're going to make an appropriate assessment, you're going to see them again in clinic and you're going to look for degenerative nerve lesion and then refer onwards to a nurse specialist as per the BOAST guidelines without delay. What happens when you fail to reduce it in A&E? That's where it could go, you know, you try, you try, and try again.
MUSTAFA RASHID: Your SHO tries, everyone tries, you can't get it in so what are you going to do and it's about how you progress to safely doing it. And if there's no vascular compromise, there is no immediate urgency. And if you don't have the skills to address the scenario in its entirety, then it's OK to wait. But actually the FRCS, they do expect you to be able to do a delta pectoral approach and reduce a dislocated locked dislocation.
MUSTAFA RASHID: So you can't wriggle out of it, you're going to have to talk about progressing to open reduction at some point. The only time where I would caveat that is if it's a fracture dislocation of an elderly four part fracture where actually there's a reasonable chance the patient may require a reverse shoulder replacement as the definitive management at the first operation.
MUSTAFA RASHID: And you're not a shoulder surgeon, you may need to discuss that, but you may need to talk about the principles anyway so, you still can't get out of talking about it, but you can at least mention that. I would personally not do this because I'm not a shoulder specialist because there's a reasonable chance this patient may require a reverse
MUSTAFA RASHID: blah blah, blah, but the principles are as follows. They may talk about the outpatient management in clinic. What kind of imaging, why, what lesions are you looking for? If it's someone who isn't a barn door or arthroscopic Bankart repair type patient, how are you going to actually manage them, what's your pathway for physio,
MUSTAFA RASHID: what are you going to ask the physio to work with? That's all kind of subtle and important things. Essentially what you're looking for is restoration of range of motion, strength, and ensuring that they understand how to regain a normal proprioception in the context of a dislocation. So that's all about core stability, tt's about scapular control,
MUSTAFA RASHID: we talked about that and then just refer back to the BESS guidelines, they're there to help you. And think of them like the BOAST guidelines, you know, if you talk about open fractures, you're not talking about the BOAST guidelines, then you'd probably miss the boat there. Same with this. You got anterior traumatic anterior instability in the shoulder,
MUSTAFA RASHID: just talk about the BESS guidelines. they're there to help you. So case number two, 23-year-old recreational rugby player, had a second dislocation four weeks ago, reduced in the emergency department. The first dislocation occurred whilst playing rugby 18 months ago. He works in an office, is fit and healthy, he plays rugby every other weekend and he's seen in the outpatient department with feeling of instability when he abducts and externally rotates, the classic at risk position at risk position of your shoulder.
MUSTAFA RASHID: You may get shown this, this is some rugby league player I found on Google. You had a dislocation and they may, I don't think they will, but they could show you something, some form of imaging that is trying to point you towards the fact they've lost glenoid bone. So that could be the other type of scenario that you may get because you need to understand that you can't just do a labral repair in this context,
MUSTAFA RASHID: it's highly likely that it will fail. You've got a male contact athlete with glenoid bone loss, they're really pushing to talk about bone loss in the context of instability. You don't need to know too much about it other than that, if you've lost bone put bone back. So always look for bone loss, commonly on the humeral head, but also on the glenoid.
MUSTAFA RASHID: There are some axial cuts that they may show you on radiographs where you'll see quite obvious rounding off of the anterior glenoid. They may show you a cross sectional axial of CT scans. They may show you a lot of things, but just always comment on the glenoid. If you if you get imaging just to see if there's a Bankart fracture there or just loss of glenoid bone, which often happens over time.
MUSTAFA RASHID: If it's unclear, get more imaging. MRI is probably the gold standard, but for bone loss, have a low threshold, for CT, it's easier to get, it's more accurate for quantifying the percentage of bone loss. You've got to remember, you know, 20% bone loss is only really about five or six millimeters in the glenoid, there are small amounts and and we know that CT is more accurate for bone than MRI.
MUSTAFA RASHID: If bone is lost, put bone back, and I would say the Open Latterjet is probably the gold standard in this country. Don't start talking about bone block procedures unless they specifically ask you. The Open Latterjet is something that you should be able to describe and describe how it works, what the principles of it are, and the anatomy of it. Look for pertinent risk factor recurrence. OK? Bone loss,
MUSTAFA RASHID: young male, contact athlete. And finally, case number three. This is the classic case that you often will get. 77-year-old nursing home resident with dementia, complaining of pain for the last two weeks to their carers. History of falls, hypertension TIA,
MUSTAFA RASHID: reasonable quality of life, only really needs assistance with preparing food and shopping and ambulates independently. There's a couple of nuances here, right? The dementia, nursing home, 77, OK? That's all relevant because what you really need to pick up in this kind of scenario is that the pain for the last two weeks is a red herring,
MUSTAFA RASHID: this could have been dislocated for months. And in fact, it has been dislocated for months until proven otherwise. So, the way you fail the scenario is you start hoicking on this little old lady's shoulder in A&E recuss, trying to reduce it, people often do. You will break her humerus if you do so.
MUSTAFA RASHID: So it's a chronic locked posterior dislocation until proven otherwise. OK? This is the X-ray they may show you, you may say this abnormal contouring of the proximal humeral head, it looks like a light bulb sign, I can see a Hill-Sachs lesion with a trough line sign and the glenoid fossa looks vacant. This is all in keeping with a possible locked posterior dislocation.
MUSTAFA RASHID: I would like to get another radiographic view to confirm this. They don't have any, but they may show you, they won't show you videos, but they may show you a single axial slice of a CT. And you can see this is here, the articular surface of the humeral head. That's the LT, that's the GT, the bicipital groove is just here and so this articular surface is meant to be here.
MUSTAFA RASHID: You can see, this is a locked posterior disclocation, and you'll have to believe me when I say to you, there isn't a lot of sclerosis here so this may be an acute CT scan, this is not the same patient, this is some patient off Radiopaedia. But you can see there's not a lot of chronic changes here so this may be more of an acute, but often what they'll show you something with a lot more sclerosis, a lot of calcifications, osteophytes, degenerative changes in the fossa,
MUSTAFA RASHID: these are all signs pointing towards a very chronic situation. If you're doing really well, they may ask you how you're going to manage this, and you need to basically talk about your assessment of how acute you think this is. If it is genuinely a few weeks and the CT scan does not show any chronic, sclerotic changes to the joint surfaces,
MUSTAFA RASHID: you may consider doing something called a modified McLachlan or a McLaughlin procedure. So the McLaughlin procedure was described, Aargh, I forget his first name. What was his name: McLaughlin, like 1950 and then like JBJS and he basically just did a subscap medialization compared to what it was. He took the sub scap off and then he put it in to where that reverse Hill-Sachs defect is OK, and it's basically like a remplissage slash subscap transfer to avoid that defect then falling back into the glenoid rim. A modified
MUSTAFA RASHID: McLaughlin is where you take an LT osteotomy, so you take the lesser tuberosity with the subscap and you then medialize that into the reverse Hill Sachs lesion and you're basically filling in that impaction fracture by taking a vascularized graft essentially, which is the subscap would be lesser tuberosity and you're fitting it into that defect.
MUSTAFA RASHID: So that's a modified McLaughlin. You can do other things in a 77-year-old if it's unstable, after doing your modified McLaughlin, you may choose to take it down and do a reverse. OK a reverse is a very powerful way of bailing out that scenario. But you don't want to be doing a reverse in a 50-year-old with this problem.
MUSTAFA RASHID: So if they're 50, you're more likely to do a modified McLaughlin and try and stabilize it. If it doesn't stabilize after a modified McLaughlin, then you may even choose to do a bone block, not at the same time necessarily, but that's really getting into level eight questioning there. But essentially, if they're younger, you're more likely to try and salvage the head, unless it's incredibly chronic, then you're going to have to do a reverse.
MUSTAFA RASHID: Assume chronic until proven otherwise, the top tip for this scenario, it's really quite key. Bringing out the nuance of decision making, explain your rationale. OK? There's lots of different things you can do, the commonest is a modified McLaughlin. You can do bone graft if it's really acute, and you can treat it like an acute fracture,
MUSTAFA RASHID: you can elevate the fragment and fill some bone void filler behind it. If it's an older patient with chronic changes, just your bailout is in reverse. It's not uncommon in some patients like this to do nothing, just to do nothing if they're super high risk for surgery, and that they've got a bit of aching, but not in agony all the time,
MUSTAFA RASHID: and their risk for having a perioperative complication is really high, then you can leave them. They'll get very poor function, but the pain usually subsides. So modified McLaughlin bone graft reverse are the main options, really. The reverse is a safe option in those over 65, but it's not without risk. It's technically a very difficult reverse to do
MUSTAFA RASHID: and it's not uncommon that that reverse will become unstable if it's not done correctly and tensioned properly. Thank you very much.
SHWAN HENARI: Thank you. A few questions.
MUSTAFA RASHID: Abbott asked me to remind everyone about the feedback.
MUSTAFA RASHID: Be grateful you can fill in the feedback form, but let's move on to questions for the time being. Shwan, have you got any?
SHWAN HENARI: So, if you remember, there was, we will come back to that on track off track. Yep yeah, we'll come back to that in a second. In terms of anesthesia for reduction, would you consider local or intra articular is described?
MUSTAFA RASHID: It is described. You can also get a regional block and do a reduction that way. We've done that at Wrightington a few times. It's not a common thing so I bet you don't start coming out with fringe answers in your FRCS. Stick with mainstream is my advice and the mainstream is appropriate sedation in the emergency department recuss.
MUSTAFA RASHID: If that's not available, or the patient's risk factors are too high, get anesthetic support and get a general anesthetic and do it under muscle relaxation.
SHWAN HENARI: Sorry, so you, so this provokes an exam from your examiners raised eyebrows and it provokes it wakes the bear which is what you're going to do let (sleeping dogs lie).
MUSTAFA RASHID: Don't start saying things that perks them up.
SHWAN HENARI: automatically, when someone says that to me, I'm going to ask a couple of questions. Your anatomies disrupted, how are you going to find your place to inject? Number one. Number two, what happens if that fails? Number three, what if what local anesthetic are you going to use? I'm going to be really grilling into your local anesthetic.
SHWAN HENARI: And we know that some papers have shown that there may be a risk with high levels of local anesthetic or cartilage damage so then that brings up that question as well so I'm not saying you shouldn't give local anesthetic into a joint, like knee surgeons are doing arthroscopy as often do, but you have to be aware that there are risks associated with what you're doing as well.
SHWAN HENARI: And the fact that you bring it up means you're going to be grilled really down to the minutia in this topic straightaway because it's unusual and it means you're provoking, They're now wondering if you're a safe surgeon or not.
MUSTAFA RASHID: Yep I agree. The other question is about how do you reduce a locked posterior dislocation? It's a delta pectoral approach.
MUSTAFA RASHID: It's often very difficult. You often have to have the patient fully relaxed. The anatomy is distorted, obviously, on the way in. The key really is, be patient, get a Hohmann retractor in between the humeral head and the glenoid and just walk it off the glenoid, it can be very difficult to do. If you have an anterior, locked anterior dislocation, the commonest thing that people do is they struggle to fish the head out and they wrap their instruments around the brachial plexus because it's really not that far away.
MUSTAFA RASHID: If that's, if you're struggling to do that, the safest thing is to take the coracoid down and so you can make more space for yourself anteriorly. But a locked posterior dislocation is a delta pectoral approach, don't go through the back, it's incredibly difficult. There's another question from Syed about how much bone loss is fixable. There's no right answer for this.
MUSTAFA RASHID: But if your lesser tuberosity is smaller than the bone loss that you've got, then you're in a bit of trouble, OK, then it'll be hard to stabilize that shoulder in a posterior bone loss, large reverse Hill-Sachs context. In acute scenarios in young people, the Americans love allograft and there are even these things called hemi-caps that you can put in, which basically are metal caps that will fit onto the different sized defects of the Hill-Sachs, again, not common UK practice,
MUSTAFA RASHID: don't start talking about that. If it's really acute, you can treat it like an impaction fracture, elevate it like you would a tibial plateau and bone graft it behind and you can do that with or without taking down the sub-scap, depending on if you can access it from the interval or not. You're not going to get asked that to be honest so. And then I'm just going to talk briefly about some bonus marks here. Can you still see my slides OK?
SHWAN HENARI: Yep, just a heads up. The bonus marks don't count if you don't get the basics right, guys.
MUSTAFA RASHID: So 100%, 100%, you not going to volunteer this but if you get asked this, you're pretty much past this stage. OK so if the examiner asks you, would you ever consider an external rotation study, what they're basically asking you is whether you know the evidence behind this.
MUSTAFA RASHID: And so basically HJA and Foys, another one of these famous shoulder surgeons who came out with this paper quite a long time ago, now, nearly 20 years ago, where he had predominantly Japanese students who had a traumatic first time anterior dislocation and he put them in this contraption, which is a custom external rotation immobilizer. And he basically found the rate of recurrence in his RCT was lower in the ER sling versus the standard sling and internal rotation
MUSTAFA RASHID: and the idea is, an external rotation, the inferior capsule is slightly more taut and so it reduces the labrum closer to the footprint of the glenoid rim and therefore it may heal in that better position and be more stable. The annoying thing about this, even though this is fantastic, there are two other RCT's that came out from North America I think, maybe one was from Australia that basically did not replicate his results.
MUSTAFA RASHID: And when I asked about him Professor ? I've actually been to Japan to visit another shoulder surgeon out there, what was abundantly clear is they have no issue with compliance, right? If the surgeon says you need to be an ER sling all the time, they will be in an ER sling all the time. And the other thing they said to me, because you won't remember, most of my population were students who worked in the big University town
MUSTAFA RASHID: and he said, you know, most of the time they're at a desk and so they're not manual laborers and they're not going to discard their sling and get back to work straight away. And so just say in the exam, if you asked about this, it's controversial, it's not commonly employed, and there was one study in Japan that suggested it's useful, but it hasn't ever been replicated and so it's not something I would consider.
MUSTAFA RASHID: And if you've ever tried to put anyone on ER, immobilizer yourself, they'll take off within a week. The patients hate this more than anything else. All right? The next thing is about Hill-Sachs. You may get asked, how do you measure a Hill-Sachs? You could use this method, the circle method, you could talk about the width of the Hill-Sachs, but what they're really trying to get at, if you're really going for the eight, if you've nailed everything else,
MUSTAFA RASHID: and they're asking you, do you know any other ways of quantifying whether a Hill-Sachs is relevant or not in the context of this dislocated shoulder, they're basically asking you if you understand between this concept of the glenoid track. Now the glenoid track basically came from again Professor Etoy [?] with an Italian surgeon called Giovanni Giacomo, Giacomo, I think his name is, where they basically looked at where the glenoid tracks on the humerus in the functional range of motion arc.
MUSTAFA RASHID: So they put die on cadavers onto the glenoid and they then cycled them through a normal glenohumeral joint and then they tracked on the humerus where the glenoid was articulated. They then created Hill-Sachs lesions and bone loss on the glenoid side to try and determine this concept of the glenoid track. All you really need to know is there are two measurements that you make. They described it on CT, John Turkish and Matt Provencher, I believe have validated it for MRI.
MUSTAFA RASHID: But what you basically need to measure is two measurements. One of them is called the Hill Sachs interval, which is the Hill-Sachs defect, plus the bony bridge up until the rotator cuff attachment and that's a number. You then need to measure the glenoid track, now the glenoid track on the cadaver specimen was 83% of the maximum glenoid width. But when you've got bone loss, the massive glenoid width is your perfect circle in the lower 2/3 of your glenoid, minus whatever glenoid bone you've got. That gives you your glenoid track.
MUSTAFA RASHID: 83% of that is your total glenoid tract. Now, the way I remember this, I got taught this by someone at the American Academy, which kind of makes sense, is if you're off track, think about it like a Formula One race car. If you're off track, you've crashed and you're likely to be unstable and therefore have to address the bone loss. OK? And off track is bad.
MUSTAFA RASHID: If you're off track, if your Hill-Sachs interval is larger than your glenoid track. You're on track, which is good, your race car is on the track, it hasn't crashed and that's because your Hill-Sachs interval is smaller than your glenoid track. Think of it like I don't know, a really wide race car and a really small track.
MUSTAFA RASHID: Yeah, if you're going around the bend, if your race is wider than the tarmac, you might crash off the road, that's off track. If your race car is narrower than the width of the bend, you're going to remain on the tarmac and you're on track and therefore you don't need to address the bone loss. This has been validated as being a pretty good indicator of who fails following purely soft tissue surgery.
MUSTAFA RASHID: If you get asked this in the FRCS for the station, you might be on for a gold medal so don't worry too much about the side.
SHWAN HENARI: Perfect. Thank you. Good feedback from one of our mentors who loves the concept of the race car off track. Thank you, everybody.
SHWAN HENARI: Once again, just thank you, Mustafa, that was an excellent talk, really well laid out and comprehensive and you made it really easy for everyone to understand.
Segment:0 .
SHWAN HENARI: OK, everybody. Once again, welcome to our FRCS mentor session. We are looking forward to a really good talk on shoulder instability by Mustafa Rashid who's one of the shoulder Fellows in Wrightington. I know every time I hear one of his talks, the topic just becomes that bit more easy and understandable. He, so, without too much delay, we'll introduce Mustafa Rashid.
MUSTAFA RASHID: Thank you, Shwan. Thank you, everyone, for giving up their evening to listen to me. Hopefully this topic, which actually does come up quite regularly in the exam. And I'll explain the cases where it comes up in. And it also came up in my EBOT exam, but this topic in particular, I'm not going to talk too much about it, but there is if there's time at the end, I can talk to you about my experience of what I got in terms of cases for shoulders in the FRCS and how that differed to the case that I got in the EBOT and it couldn't have been further apart and
MUSTAFA RASHID: it really highlights the differences between those two postgraduate exams. So let's see if this works. So OK. So the objectives today, we're going to outline the mechanism of shoulder instability and we're going to recap the associated pathologies and discuss management strategies, surgical and conservative for treating patients with an unstable shoulder.
MUSTAFA RASHID: I'm going to give you three example cases that could easily have come up in the FRCS, and then when there's opportunity, like with all the FRCS mentor sessions to do some VIVA practice at the end. So all of these athletes are experiencing shoulder instability and there's lots of different mechanisms. So quite a common mechanism is a fall onto a forward flex and abducted arm.
MUSTAFA RASHID: You could also fall as the Aussie rules football player on the bottom right, although he is struggling to cycle land directly onto the elbow that's extended and so there's an anterior and a superior directed force on the proximal humerus. And there's a couple of, there's a couple of examples there of patients that clearly have already an unstable shoulder and they do very minimal amount of exertion and it really is a muscle contractor event suddenly that is pulling the shoulder out.
MUSTAFA RASHID: And you can hypothesize that I mean, those patients, they probably had a more significant traumatic event previously and was never fully stable before it came out again. So so there is a variety of ways in which you can dislocate your shoulder, but quite commonly it's a fall, there's an element of external rotation, abduction most commonly. So if you get the scenario where you're basically presented with an acute traumatic event and shoulder pain, you've really got to just focus on the assessment and you've got to be quite quick with progressing through this.
MUSTAFA RASHID: You don't really want to get bogged down with what you're going to do in the emergency department because this is basically what you do as an ST3. It's not really FRCS level. So you want to get through, you want to confirm the dislocation and that's with clinical and radiographic confirmation. You want to assess for neurological and vascular compromise and that is really key.
MUSTAFA RASHID: That's the kind of a pass/fail thing if you don't assess the distal neurology as well as the axillary nerve and always check for a pulse, you'd be surprised, actually, some of the older patients that have a dislocation, how often they get a slightly thready pulse that often isn't picked up by your junior. So that's that. Attempt to save reduction, which is often in the emergency department and confirm the reduction clinically and radiographically and repeat the neurological and vascular assessment.
MUSTAFA RASHID: Nothing too complicated about that. It's what we do every week when we're on call, we get a similar case. With regards to the radiographs people often get really confused. Just keep it very simple you know, just say what you see. If you're not sure, if they give you just one view, just, just take your time,
MUSTAFA RASHID: say what you see. If you're unsure, hedge your bets and say, I'd like some more x-rays and more imaging please. If they give you two orthogonal views on the X ray, just say I'm really sorry, I suspect there may be instability here, but I would, I'm not 100% sure so in my clinical practice I would confirm this with a CT scan, and that's a safe thing to do OK unless it's bond or obvious
MUSTAFA RASHID: a lot of the time it's not and if you're struggling, you can say one step more than that is you can say, well, the patient obviously is having difficulty getting in the right position to get adequate X-rays radiographs. I would ask the radiographer if they're able to do a modified axial view or a velpeau view, which can often reveal that is not sitting in the deeper humeral joint.
MUSTAFA RASHID: Nearly all patients will need a repeat X-ray after you manipulate their shoulder, and most patients will require some sort of cross sectional imaging in the clinic after they've been after they've been treated for their acute event. So you may get x-rays like this, again, these are pretty, pretty obvious, you know, it's a dislocation.
MUSTAFA RASHID: And just remember, the commonest direction is antenter inferior, you know, 95-97% of shoulder instability goes in the anterior inferior direction. OK? And so that's basically what you're looking for, if you're not sure, and you're not that familiar with seeing these. If you're going to guess, it's going to be anterior inferior. OK? But you can see on the left hand view how the posterior humeral head is sat directly perched onto the anterior glenoid rim.
MUSTAFA RASHID: And so you can imagine there's normally some interposing tissue there, there's a labrum, there's capsule, things like that. And so you can see how in the dislocation you've got (a), you know, a huge amount of capsular plastic deformation for the head to be in that position, (b) the labrum has to have taken some sort of injury, whether it's an avulsion or a sort of compression event. Something has got to have happened to the labrum for the bones to be touching like that.
MUSTAFA RASHID: And, and then look at the bones. You know, the bones will have an impact. And in particular on the humeral head, that is literally an impaction fracture that you're seeing there. The humeral head in that view tends to be reasonably spherical and it's clearly not its hourglass shape now due to the impaction of the head on the glenoid rim.
MUSTAFA RASHID: So you may get something like this. This is not the same patient, although the entries do line up quite nicely. These are different patients, but this is a fracture dislocation and people often get really worried about whether you should be reducing this in the emergency department or not. The safest bet is to say not, you know, just to say that in your experience, this needs adequate muscle relaxation and with an intubated patient to avoid the risk of propagating the fracture across the anatomical neck.
MUSTAFA RASHID: And so that would be a reasonably safe FRCS answer. They will often push you in that scenario to say, well, you know, theaters have just started a 12 hour laparotomy and there's nothing, no one available, in which case, you can then escalate, discuss with your emergency physician colleagues and see if they have the expertise and ability to perform procedural sedation safely in the recuss and if they can't, then it's not unreasonable to say I'll be picking up the phone to my local trauma center because of the unusual circumstances that I find myself in without capacity to be able to do this safely.
MUSTAFA RASHID: I mean that. Yeah, you could say that but you try and defuse the situation and just make it abundantly clear that what you're trying to do is get this reduced because it's an emergency without causing further harm. But in reality, these patients with this kind of fracture dislocation, unless they're reasonably old and frail or unless the greater tuberosity sits exactly where it should be, a lot of the time this will require some sort of surgical intervention anyway
MUSTAFA RASHID: so bear that in mind. You may get x-rays like this and at first glance, this may be quite difficult to interpret, but let's just go through one by one. So on the far left, the proximal humerus on an AP projection is not meant to be perfectly spherical. OK? There's an eccentricity to the humeral head in relation to the anatomical axis of the humerus. And so if you're seeing a humeral head that sits perfectly in line with the humeral shaft, then if you were to draw a line straight down the humeral shaft, not sure if you can see my cursor if you go straight down here and 50% of the head is on either side, this is a posterior dislocation until proven otherwise.
MUSTAFA RASHID: OK this is the infamous light bulb sign because the humeral head looks like a light bulb and it's not meant to. This is also something similar. OK? There's something not quite right here. OK? You can't quite make out where the glenohumeral joint is. There's significant overlap and there's also some sclerosis within the head. Right so this is also a similar sign.
MUSTAFA RASHID: This is the trough sign and this is the loss of half would overlap sign. And then finally, the modified axial tells you the story here. This is the glenoid, yeah, relatively flat socket. This is the humeral shaft, this is the humeral head and we can see as you trace the glenoid is the anterior er sorry posterior glenoid neck and the humeral head is sat within it and
MUSTAFA RASHID: in fact, it's compressed. About a quarter humeral is missing here. And that's because of a significant impaction fracture to the posterior glenoid rib. So all in all, all of these radiographs they're of different patients, but they all describe posterior dislocation, which is, I would put it in the category of a classic FRCS VIVA's scenario, trauma VIVA's scenario, because they can take it a lot different ways.
MUSTAFA RASHID: They can write the same branch question with the same radiographs and take it you know, five or six different routes so it's a really high yield question that comes up in part two. You often get a starter like this after you've identified what it is, they'll say, what are the signs of posterior shoulders dislocation? And most people get really bogged down with the radiographic signs.
MUSTAFA RASHID: They remember light bulb sign and they go a light bulb sign. And then the examiner goes one of the other ones, and then they're just blank, so be systematic like I've talked about in my previous talks, the signs are clinical or radiographic. The clinical signs are loss of external or passive external rotation. The radiographic signs include the light bulb sign, the trough line sign, which is basically a reverse Hill-Sachs impaction fracture
MUSTAFA RASHID: so it looks like a stripe of sclerosis within the medial humeral head. There's the loss of normal half moon overlap and then there's the Rim sign which wasn't really visible on those X-rays prior, but the rim sign is essentially a vacant glenoid fossa, so it looks like a widening and the definition in some radiology text textbooks I believe is more than six millimeters, but it just looks abnormal
MUSTAFA RASHID: so just have a low index of suspicion. You're shown an X-ray of someone and the history is some sort of traumatic, minor traumatic event, and now they're struggling with pain or loss of external rotation. Just think, could this be a missed posterior dislocation? And then lastly so rotations the clinical side, really?
MUSTAFA RASHID: You often will get asked about nerve injuries, you know, you may say, well, I was, I would evaluate the distal neurology median, ulnar radial nerves, as well as the proximal neurology auxiliary nerve, so we look for any signs of deficit and then you may get asked, well, what is the commonest nerve injury you expect with a dislocation?
MUSTAFA RASHID: And the answer here, based on this paper from Holland, is the auxiliary nerve. It's most commonly affected. And what they actually found which is really quite interesting is the rate of neurological injury, where the dislocation episode is strongly correlated to the age of the patient. So the older we are, the more likely it is that you'll have a nerve injury. And they actually did a study where they gave everyone an EMG to quantify this, and they found nearly half had some degree of external loss, the vast majority of which will recover spontaneously with observation.
MUSTAFA RASHID: But we've really got to be aware of it and I've seen quite a few patients in their 70s who've got a infraclavicular brachial plexus, dense brachial plexus palsy that's taken a very long time to show signs of improvement. In the clinic, it's a different scenario, OK? It's you're in the fracture clinic or the elective shoulder clinic and you're presented with a case.
MUSTAFA RASHID: Keep it very simple. Take a history. What's the mechanism? Is it a first time dislocation? Do they have pain currently? Are they a hypermobile patient? When they had their dislocation recently, did they need reduction? That's really quite important.
MUSTAFA RASHID: Shoulder surgeons really obsess about this because the patients come in and go and you ask them, how many times have you dislocated? Oh, 17 times. And you're like OK and you look at their patch record, they've never been to any other hospital and they've only got 3x rays. So there's something not quite right. They're probably having instability episodes where they may not be having frank dislocation episodes that require sedation and clinical input to reduce it.
MUSTAFA RASHID: And that doesn't necessarily mean that it's not relevant that they're having these several episodes. It just means that either they're so unstable the patient has learnt how to reduce it spontaneously or more likely they're perching and coming back to the center of the glenoid fossa. So that's quite important. With your examination, again, look, feel, move, special test.
MUSTAFA RASHID: The same thing that we learnt when we were junior registrars. In special tests, don't forget apprehension. I always do my apprehension supine. You can do it standing up, but supine is usually preferred and remember, there's a few little tricks for this, but you just got to instill confidence in the patient and take it very slow. So what I often tell the patient, I get them to lie down,
MUSTAFA RASHID: I ask them to bring their arm out to the side with the arm entirely rotated. So like this much, imagine they're lying down. I then put my elbow sorry my hand behind their elbow and I ask them, imagine my hand is like a coffee table. Rest your arm, rest your elbow onto my hand and then I say to them, let gravity bring your hand down. So I'm like letting them relax and allowing passive external rotation with the assistance of gravity.
MUSTAFA RASHID: Now once you get to around 70 degrees axial rotation plus, you'll find the patient feels uncomfortable and they'll never tell you I feel like I'm getting this pain. Patients do, but often I'll say to them, does that feel weird? Does that feel uncomfortable? Does that feel like it's not sitting in the joint properly? Does that feel like it might come out? And they often say yes.
MUSTAFA RASHID: In which case you then apply a posteriorly directed force to the proximal humerus and you keep it there. And you say to the patient, does that get rid of that uncomfortable sensation? And if they say, yes, that's apprehension, positive, and Jobe's relocation test positive and often you can do rebound test. So you let go of that post aggressive force and they will get apprehensive again.
MUSTAFA RASHID: But that's a bit mean. But I would say that the key one for me is when I recenter the humeral head in abduction external rotation, I push back with a reset of the humeral head, it then relieves that proprioceptive stretch on the anterior inferior capsule, and they feel like that's where the humeral head is meant to sit. And so that apprehension sensation goes away
MUSTAFA RASHID: and that is really quite a sensitive sign. In older patients, always assess cuff integrity so resisted abduction into rotation, resisted external rotation, and some sub sat tests, whichever you like and again, always talk about neurovascular status, but don't talk about it like that, split it up into median, ulnar and radial and axillary nerves. When it comes to your imaging in the clinic, start with radiographs.
MUSTAFA RASHID: There are some special views you can get to identify a Hill-Sachs lesion and a glenoid rim fracture. Don't worry too much about that. Just ask. At the very least, an AP and an axial. And then there is some debate about what form of cross-sectional imaging you get. In common practice, It's MRI in some centers, it's an MR arthrogram.
MUSTAFA RASHID: And the radiologists debate about this quite a bit, I mean, the literature is actually quite clear. The MR arthrogram is more sensitive to picking up capsule labral injuries, but often there's logistical issues with getting those in numbers. There's limitations and MSK radiologists are unable to do the arthrogram, you know, that takes time and availability is the biggest issue. And some people now argue if you have a three test, plain MRI, it's just as good, which is probably true.
MUSTAFA RASHID: But you know, the gold standard is the MR arthrogram. The examiner may ask you, well, if they had an acute injury and you have access to a scan within a week or two, do you need the arthrogram? And what they're basically getting at is for you to understand that the hematoma caused by the injury acts like a contrast, and a plain MR may actually be sensitive enough to pick that up.
MUSTAFA RASHID: Ultrasound scan is probably the mainstay for the over 40-year-old patient with an instability episode because it's the most easily accessible way of assessing the integrity of the rotator cuff. And most shoulder surgeons believe that an acute traumatic rotator cuff tear picked up early should be treated early with an operation. And that has been challenged by a Swedish study relatively recently.
MUSTAFA RASHID: But that's still the prevailing sentiment within the shoulder community. So if you get a person over the age of 40 who's had a dislocation, so get an urgent ultrasound if there's a full fitness rotator cuff to get them into theater. And in some places they even go onto the trauma list for the shoulder surgeons to do an acute cuff repair. But in most places they probably get listed as a PE two semi elective acute case on the elective shoulder list.
MUSTAFA RASHID: In some places they get a CT or a CT arthrogram. I worked at one place where that was their mainstay investigation. It's very common in continental Europe and France in particular. And I can see the logic for this as well. I think it probably it might be my preference as well as a consultant, because if you have a young person with a traumatic anterior dislocation, you almost certainly can bank on the fact that they'll have some sort of anterior inferior capsule labral injury of some variety.
MUSTAFA RASHID: And in reality, if they're going to proceed to require surgical stabilization, you will see that with arthroscopy. One thing that does change your decision making process is if they've got bone loss and people argue to death about how accurate MRI is versus a CT scan, but CT scan still remains the gold standard for assessing bone loss. And so if you were to have one cross-sectional imaging investigation that will profoundly determine how you manage the patient, I would argue that a CT is probably it because that's the most accurate way of determining whether there's bone loss.
MUSTAFA RASHID: And bone loss is what really determines whether the patient will have a soft tissue procedure or not. It's just something to think about. The safe answer is an arthrogram if available? Plain MR if the consultant radiologist feel's that that is probably accurate to pick up capsule labral pathology. That's the safe answer. Also the clincher, just be wary of this.
MUSTAFA RASHID: Right so if you have a look very carefully, this is a young man who's had an instability episode and he's got some abnormal scapular movements here. He's getting early retraction and some flexion are prominent in for a medial angle of his scapula. This is very common and a lot of this can be rehabilitated. But patients often won't tell you oh it feels weird on my scapula. They'll just say, my shoulder hurts easier because you've lost the normal proprioceptive pathways, of which the anterior inferior capsule labral junction provides a significant contribution to.
MUSTAFA RASHID: So I think my mic might have cut out then so I'll just repeat that. If you see some sort of scapular asymmetry on clinical examination in someone who's had a relatively recent instability episode, that is probably the fact that they've got a capsular labral injury and loss of the normal proprioceptive mechanisms to ensure that they know where their scapula is positioned in relation to the glenohumeral joint. And so this is quite a common thing that often will rehabilitate back to normal but often won't
MUSTAFA RASHID: and so you've got to look for it as well. No talk on shoulder stability is complete without mentioning Arthur Bankart. He was a London based surgeon in the 20s to 50s he's a bit of a legend, really, in shoulder surgery and he was really quite annoyed at his time in the 20s and 30s when there were over 100 operations prescribed for doing various things to the shoulder to stabilize it.
MUSTAFA RASHID: And his view was that everyone was just not seeing the lesion, they were not seeing the pathology. And so he advocated taking down the coracoid, which no one really does nowadays, but taking down the coracoid to fully expose the anterior inferior labrum and the capsule and the glenoid rim. And then he says, you will find the essential lesion is what he described, which is this anterior inferior capsular labral avulsion from the glenoid.
MUSTAFA RASHID: And he actually called it the bigger glenoid ligament and he actually thought the labrum often didn't heal very often so he would excise the labrum and attach the capsule using dental drills and catgut sutures directly onto the glenoid face and that was his technique and then he would wire the coracoid process back on. But the Bankart lesion is an anterior labral detachment. And the thing to say about the labrum, this is an important point, is the labrum is dense in proprioceptive nerve fibers.
MUSTAFA RASHID: It also really is a conduit, so the capsule in the inferior glenohumeral ligament to attach to the glenoid bone. And that's really what the labrum does. And so if it's detached, it's not really a bumper you know, look at how flat the glenoid fossa is and look at how much it's deepened by the labrum, this is not enough to stop this giant humeral head from dislocating, right? So it's not really a bumper,
MUSTAFA RASHID: that's just rubbish. It looks like a bumper, but in reality that's not how it functions. It's predominantly a proprioceptive structure and so it allows your brain to know where the center of the glenoid fossa is in all positions of putting your arm in space. And it also allows the static check raise of the capsule in the inferior glenohumeral ligament in particular to attach the glenoid and be functional.
MUSTAFA RASHID: There are a number of other associated pathologies, some of which are described here. This is a very famous Google image which I'm not actually sure where it comes from. I've seen this in so many slides and then the MRI slice sequence, the coronal scan that we see there is demonstrating a Hagel lesion, which is a glenohumeral ligament avulsion from the humerus.
MUSTAFA RASHID: So not from the glenoid but from the humeral side. My advice to you about the associated pathology, if you get asked the question about this, is just keep it simple. So just say, OK, the Bankart cartilage is the essential lesion. So that's the thing that you're most likely going to have in a traumatic anterior shoulder dislocation. Or you may have that plus some bone which would make it a bony Bankart or some periosteum, which could be a Perthes lesion
MUSTAFA RASHID: and if it's stuck down medially it's a ALPSA lesion or cartilage, which is a GLAD lesion, it doesn't really matter what they're called, just don't get too bogged down with that. But each of these is a slight variation on a theme. It's the anterior inferior glenoid rim plus capsule plus bone issue. And then the capsule itself can have detachment, as we've said, either from the glenoid, which by definition is what a Bankart lesion is.
MUSTAFA RASHID: It's the capsule attachment to the labrum, which is no longer attached to the headline rim or more commonly it's often missed is a detachment from the humerus. If you ever see a Hagl lesion, these patients are profoundly unstable in clinic. They really don't, their shoulder is terribly floppy. It sits within a very capacious volumous bag now within the capsule, because there's nothing really attached.
MUSTAFA RASHID: So be aware of those patients. They often will be apprehensive, even at low levels of abduction. You may get shown a radiograph like this and they'll say, what do you think? And you can say that the glenohumeral joint is endlocated here, but we can see a significant impaction compression fracture of the posterior humeral head in keeping with a Hills Sachs lesion.
MUSTAFA RASHID: So Hill Sachs, two people, both radiologists, both American Harold Hill and Maurice Sachs, they actually didn't describe the lesion. They just popularized it. It was described many years earlier by someone called Eve. Soon after, the discovery of x-rays by Wilhelm Roentgen, who I think had his anniversary of the discovery not so long ago, maybe last week, but they really popularized it and said that you know, we should be looking for this.
MUSTAFA RASHID: They were both radiologists. Then various surgeons came along in the Nougties and described this concept of the engaging Hill Sachs lesion, which came and went very quickly, actually, once people realize that every Hill-Sachs lesion engaged at some point in its lifetime, right, but what they were really talking about and this is really Steve Burkhardt's work from San Antonio, Texas, is, he described at the time arthroscopy, bringing the arm up into abduction, instead of rotation to see if he could get the impaction divot fracture of the Hill Sachs lesion to actually perch onto the glenoid rim.
MUSTAFA RASHID: And this is what that looks like. You can see this is quite a bad shoulder. The thing that you're looking at on the right is the humeral head. Let me just see if I can play this again. And you can see that's a very large and very wide Hill-Sachs lesion and you can see how as the arm gets externally rotated, this can quite easily engage onto the anterior glenoid rim.
MUSTAFA RASHID: Bony Bankart we talked about. These most commonly will require surgery. you know, think of it as an articular fracture., you know, this should be treated as such. When these are missed, it's often quite difficult. I mean, the patient has a miserable time, they go down the elective pathway, which in the current climate of COVID in the NHS is often taking months to get to a surgical, definitive resolution.
MUSTAFA RASHID: And so this is very unstable, especially if it's displaced, especially with a significant portion of the glenoid rim and so this is not a very pleasant thing to have to live with and go back to work with whilst you're waiting your elective operation. They often need a CT to better assess them. A lot of the time, we've picked these up late.
MUSTAFA RASHID: The fragment is displaced, medially, and then stuck down to the glenoid neck and that's quite a shame and if that's a significant portion of the glenoid rim, then really any soft tissue procedure, any acute surgery to try and heal the fracture in the correct position is lost then at that point and so then you have to do something to replace the bone that's lost.
MUSTAFA RASHID: We briefly talked about what imaging - there's a nice paper that looked at this. Lots of different studies have looked at it, lots of narrative reviews but essentially the consensus is thought to be that three Tesla scanners are better than 1.5. Tesla scanners for picking up capsule labral pathology. In North America, it's very popular to do this ABER position this abduction external rotation position in the scanner, which is thought to be quite beneficial for improving the sensitivity of imaging.
MUSTAFA RASHID: We do it in variable amounts in this country I would say, in the places I've worked. They concluded that MR arthrogram is much 96 was 93% better for picking up labral lesions, but in terms of detached labral fragments, it was highly, significantly more sensitive and that's purely because you've got the contrast going around that fragment on the arthogram, which you don't have in the MR.
MUSTAFA RASHID: And then the important thing to know is that you can miss lesions with the MR, it's not infallible, but it is, it is slightly more sensitive, even though it can be quite challenging to organize that in your setup. So try to think of the associated injuries, a bit like a ladder of ascending things that make you more and more unstable and more likely to push you towards surgical intervention.
MUSTAFA RASHID: So you've got your Bankart lesion, which everyone pretty much gets. You've got your Hill Sachs lesion, which again, most people get for varying degrees. You get large Hill-Sachs lesions, you get small Hill-Sachs lesions and we'll talk a bit more about that later. You can get your ALPSA lesions, your GLAD lesion, Perthes lesion, all these other extensive periosteal sleeve avulsions or cartilage plus periosteal sleeve
MUSTAFA RASHID: avulsions that you get, they will make you generally more unstable. A Bony Bankart, by definition, you've lost bone from an area of the body that is notorious for not being a large socket, large bit of bone, and that makes you significantly more unstable, and then as we talked about earlier, the top thing is if you have the Bony Bankart, a large capsular avulsion from the humeral side and the Hill Sachs lesion, that patient is going to be profoundly unstable,
MUSTAFA RASHID: so think of it like a ladder of ascending associated pathologies. You may get asked about how you classify instability. Lots of different ways to do this. In the UK. I guess the standard, because it came from Ian Bailey and the Stanmore group many years ago now is probably the Stanmore triangle. You should probably know about this for the exam. Essentially, the Stanmore triangle is three polar types and you need to appreciate that patients don't have to sit on the corners of this triangle,
MUSTAFA RASHID: they often rarely do, actually. They'll have contributions from all three polar types. And the important thing to note is that there are temporal changes and patients can move within the triangle depending on rehab, the time since injury, et cetera. And so now, you, Anju Jaggi, who's the Senior Physiotherapy Consultant at Stanmore, talks about the Stanmore prism as the patient moves through within that triangle through time.
MUSTAFA RASHID: But generally speaking, your acute young recreational sporting traumatic anterior instability is likely to be most commonly a polar type 1 injury. But you need to be aware that there are polar type 2 injuries, and these are patients that are hypermobile that may have a traumatic event but often don't, or the trauma is very minor, not really significant enough to warrant association with possible labral injury.
MUSTAFA RASHID: They often won't have a Hill-Sachs lesion on the X-ray, that's a big giveaway for these patients, you do an MRI, you might see some chronic changes in the labrum; doesn't look detached, but there's no Hill-Sachs lesion and that's because they're so hypermobile, they don't, there's never enough constriction within the soft tissues for that impaction fracture to occur as they sub blocked or dislocate.
MUSTAFA RASHID: And then you get the type threes, which a lot of us have come across in on calls in A&E. They tend to be quite young, they tend to have a variety of issues, they come in very regularly to the emergency department with a dislocated shoulder, and these are a complex group of patients to treat, and they almost certainly do not require an operation. Same with the polar type twos,
MUSTAFA RASHID: they rarely need an operation unless there is a significant traumatic event that creates a structural lesion and someone who was previously quite hypermobile and even then it can be very difficult to treat them surgically. The vast majority mainstay of treatment for type twos and 3's is physiotherapy. Type one is often surgery, but we'll come on to that. You may get asked about risk of recurrence, and you really do need to know this paper, one of the many landmark papers by Mike Robinson in Edinburgh.
MUSTAFA RASHID: I mean his work is truly quite amazing and this is a good example of that. This is a study looking at the two year recurrence rate following a first time shoulder dislocation. And what he basically found, he kind of built on the work of a chap called Leonard Hevelius, who worked in like The Mayo in Sweden, which is really Northern Sweden, Arctic Circle, who wrote a bunch of papers in the 90s and early noughties looking at long term follow up of shoulder dislocations,
MUSTAFA RASHID: and what he basically found was your lifetime risk of recurrence is directly linked to your age of first dislocation. And Mark Robinson did this in a very elegant way in Edinburgh, where he looked at the two year recurrence rate and found the same thing. And he gave us these nice relative risk ratios of recurrence after first dislocation based on age. But he also demonstrated that if you are male, that was also a significant risk factor for recurrence.
MUSTAFA RASHID: So you can see that the two year recurrence rate is actually significantly different between men and women. So this is quite a useful thing to think about. The way I tend to remember it is at the age of 27, you've got a 50% chance as a bloke to have another dislocation if we did nothing within two years. And similarly, if you, a very young female, 16, 17, 50% risk, that's one way to remember it.
MUSTAFA RASHID: The other way I remember it as if you're under 20, you've got an over 75% chance of having a two year recurrence if your dislocation was at that age. So you need to know this, that's quite key for FRCS. And don't worry too much about this, but people have tried to quantify your risk of failure following an arthroscopic Bankart repair, and this group in Nice: Pascal Boileau, a very famous shoulder surgeon who described the ISIS score before ISIS, the other group.
MUSTAFA RASHID: And he basically said, if you've got more than six points, that correlates to a 70% recurrence risk and a mean of 31 months. But this kind of study based on retrospective data is probably not the thing that you really want to be quoting for your to hang your hat on in terms of decision making. But what it did do is kind of quantify to some degree the risk factors for recurrence following a soft tissue procedure, so you can see them here on the left.
MUSTAFA RASHID: If you're very young, if you're playing competitive sport, if you're playing contact sport, if you're hyper lax, if you've got a large Hill-Sachs lesion, and if you've lost some bone on the glenoid side, these are all risk factors that he thought increase your risk of failure with a Bankart repair. And interestingly now Pascal Boileau is very famously to have said that all of his patients, regardless of amount of bone loss, will get an arthroscopic Latter-Jet procedure,
MUSTAFA RASHID: so he didn't do any Bankart surgery, which is definitely not a view that you want to trot out in the FRCS because that's not the common UK practice currently. This is a video of a surgeon that I went to visit in Colorado called Peter Millett doing a Bankart repair. I'm just going to let this run, I won't let it run all the way through but it's really nice for those that haven't seen much arthroscopic shoulder surgery to understand what's going on here.
MUSTAFA RASHID: So we're viewing from the posterior portal. This is the left shoulder, this is the probe coming in and you can see it, the probe just falls down in between the labrum and the glenoid rim. You can see this is quite an acute scenario. This is in America where you can see a lot of hemorrhage so this patient would have dislocated not so long ago and you can see there's quite a capacious, inferior recess, the IGHL is d tension.
MUSTAFA RASHID: That inferior sling is not tight at all and what you'll see here, he'll debride some of the frayed tissue and start to mobilize the labrum. As you can see here, he's going to bring in oh, he's going to show you the Hill-Sachs lesion there very quickly, we'll come back to that in a moment. He's testing the superior labrum to see if there's any extension superiorly of this labrum detachment. Here's the Hill-Sachs lesion again.
MUSTAFA RASHID: This is quite a deep but narrow hills occlusion. And so he's dividing some of the frayed tissue here with a soft tissue shaver, and that's using a periosteum elevated arthroscopic lead to really elevate the labrum and the attached capsule to it. He then is making his anterior portal and using a hook probe here to
MUSTAFA RASHID: release the tissues from further. It's often quite a useful step because then you can see how mobile now the labrum of the capsule is to be able to re-tention it onto the glenoid rim and then he's basically going to prepare the glenoid, pass some anchors and re-tention the glenoid rim. I'm just going to see if I can show you the final construct, what this looks like.
MUSTAFA RASHID: So you can see here, you can see here that the bumper, if you like, has been reconstituted. That's not really what's important, the important thing is you reattach the capsule via the labrum onto the glenoid rim. So now once that's healed, you've restored your proprioceptive feedback mechanism
MUSTAFA RASHID: so that you now know where the anterior glenoid rim is, so you can keep the head centered using your important dynamic stabilizers of the shoulder. OK. There is a Cochrane review on this topic. It basically concluded that primary surgery in young men with highly demanding sporting and physical activities after the first dislocation is, is probably warranted. But there's no evidence of which type of surgery is the best, and that's probably fair to say.
MUSTAFA RASHID: It's important for you to mention this in the FRCS. Yes this is the best guidelines. There's a few pathways. There's one for traumatic anterior, there's one for a-traumatic and there is one for multi-directional instability, which we're not going to talk about. But they came out with this suggested algorithm for treatment. If you're under 25, you should be referred to a shoulder specialist for secondary care
MUSTAFA RASHID: You should be allowed to mobilize as soon as the pain allows. You should be assessed by a shoulder surgeon within six weeks and have some imaging and consideration of arthroscopic anatomic repair. If you're 25 to 40, you should be reassessed at 3 to six months in the shoulder clinic and if you remain symptomatic, have the same diagnostic imaging and treatment.
MUSTAFA RASHID: If you're over 40, you should be assessed early in terms of diagnostic imaging and shoulder specialist and have an early rotator cuff repair if clinically relevant, that's not always the case. and if you're 90 years old, it's OK. The chance of you having a cuff, cuff tear before you dislocate it is incredibly high and so you're not going to start repairing all those 90-year-old cuff tears.
MUSTAFA RASHID: But if you're 45, previously normal shoulder and dislocate, you've got a full thickness cuff lesion, then they advocate you should probably be repairing those early. So you can always fall back on the best guidelines, they're not particularly well evidence based because there isn't a great evidence base for this, but that's what UK practice tends to be in this country. And you won't get asked about this, I don't think but if you get a Hill-Sachs lesion at the time of a Bankart repair, some surgeons advocate doing something called a remplissage, which is a French word that means to fill in.
MUSTAFA RASHID: You're filling in the defect by putting the capsule and the infraspinatus tendon into that defect and I'm filling it in so that as the patient externally rotates and abducts, this defect is now filled with soft tissue and cannot engage onto the glenoid rim. That's a remplissage. Some surgeons like it, a lot of surgeons don't use it. You do need to know about Laterjet.
MUSTAFA RASHID: Laterjet is essentially a corocoid transfer operation for, in this country, predominantly glenoid bone loss. And so you basically take the coracoid with the conjoined tendon attached to it off. You make a split into the subscapularis and you attach it usually with two screws into the glenoid. And you basically, when you've got a flattened anterior glenoid surface and you've lost bone, the glamma is meant to be pear shaped,
MUSTAFA RASHID: If it's not pear shaped, you haven't got much of a socket for your head to stay on and therefore you're widening the socket and you're increasing the distance required to jump the bone to dislocate. That's the primary, that's one mechanism for keeping this and making it stable. The other mechanism is, as you can imagine, as you abduct and externally rotate your arm, the conjoined tendon then creates an inferior sling or hammock and adding a dynamic soft tissue constraint to dislocation.
MUSTAFA RASHID: And so those are the two primary mechanisms for a Laterjet. And if you'd really getting on to an eight, you may be asked to talk about the variations of a Laterjet. So this is the traditional Laterjet, this is what's called the congruent art technique developed by Joe de Beer and Steve Burkhardt in 2004. And they basically just rotated the coracoid 90 degrees and fired the screw through the thin axis of the coracoid, which is a little bit more unforgiving.
MUSTAFA RASHID: It's about 4 millimeters versus 7 millimeters. But the benefit of this is the angle perfectly matches the curvature of the glenoid fossa and it also increases your graft width. So that's called a congruent art technique. The surgeon that I work for at Wrightington - Professor Len Funk; this is his preferred technique. And he treats a lot of professional rugby players with Laterjet using this technique
MUSTAFA RASHID: so it is very effective and powerful. The alternative is a bone block procedure where you're taking either iliac crest, distal clavicular or allograft and you're bolting it on to the front of the glenoid to reconstitute the missing bone from the glenoid side. It's technically more anatomic, if you like, because it's not you're not transferring anything from anywhere else,
MUSTAFA RASHID: you're addressing glenoid bone loss. The problem is this is dead bit of bone that you're asking to heal to something that isn't particularly well vascularized. And if it doesn't heal, and resorbs and that's a problem, because then you've got hardware, you've got metal screws that are prominent in the shoulder. But you can do arthroscopy or open,
MUSTAFA RASHID: you can do it with a variety of different auto or allografts. This is often described as an Eden-Hybinette procedure named after the Swiss surgeon who perscribed it. So just like we talked about with associated pathologies, there's also a surgical ladder for stabilization. Conservative management. Arthroscopic Bankart repair, plus or minus remplissage. An open Bankart repair, you could argue, although it's not very commonly done anymore,
MUSTAFA RASHID: I would argue it's a very powerful way to stabilize a shoulder because it allows you to reattach the capsular labral tissue, but it also allows you to address capsular redundancy by double breasting the capsule ostomy that you make. So most people will do a t-shape capsulotomy and you can bring the two leaves over each other and reduce that capsular redundancy. Then there's bone block procedures, a Laterjet procedure, and then you can get into the weirder, wonderful art commonly done in this country,
MUSTAFA RASHID: but they are in North America, which is a distal tibial allograft. If you get a dislocation case in someone who's over 40 years old always, always think about the rotator cuff, forget the labrum, that's not important in this age group as much as the rotator cuff. Rotator cuff will determine the outcome of the patient
MUSTAFA RASHID: and also the rehab. So if you get someone who dislocates after the age of 40, just think about the rotator cuff. And get some early imaging within two to three weeks to assess for a cuff tear. And if you do see it, you will see it in 35 to 86% based on the literature, the cuff tear guides the management and rehab for that patient. You know, there's debate about whether you address the labrum at the same time of doing the cuff repair,
MUSTAFA RASHID: A lot of the surgeons don't bother because if you had a 40-year-old who didn't have a cuff tear when it dislocated and just had a labral lesion like a Bankart lesion, the risk of recurrence at the age of 40 plus is very low so you wouldn't ever offer them surgery. So a lot of surgeons are more than happy to ignore that and just treat the cuff tear acutely. And I think that's right.
MUSTAFA RASHID: Just one slide on posterior instability, it doesn't come up that much in itself other than in one very specific scenario, which we'll come on to. It's very easy to miss. Look for the subtle signs and the lack of passive external rotation. Posterior apprehension test is not as useful, you got taught that in medical school and as I say, it's just not as useful for posterior stability but pain posteriorly,
MUSTAFA RASHID: There's very few things that patients describe pain at the back of their shoulder, in their joint line. But one of them is often a posterior labral injury. And that's often worse if you get them in this position and to resist elevation, that makes it worse because they're basically trying to stabilize the humoral joint and they don't know where the back is so their dynamic stabilizers are firing, but they're not centering the humeral head
MUSTAFA RASHID: and so that pain often gets worse because they're pushing onto that posterior and capsule labrum. And most do not require surgery unless they're quite high level athletes or feel very unstable as well as painful. So the FRCS case that you tend to get, you get your bog standard traumatic anterior instability because there's lots of nuance, right?
MUSTAFA RASHID: You can vary the age, the gender, whether they play contact sports and you can have a discussion about all the associated pathologies. So that could come up. You don't tend to get the atraumatic MDI multidirectional disability type III muscle pattern or type instability, that's probably a bit unfair to get that. You do quite commonly get fracture dislocations. So approximately you haven't really talked about or displaced gd fractures.
MUSTAFA RASHID: And the one thing that I talked about earlier, which we'll come on to is you do very commonly get the locked posterior dislocation, often in a slightly older patient. So let's go through the cases, shall we actually just take a 2 minute break to take questions? Shwan, do you have any questions at all there?
SHWAN HENARI: Yes sorry.
SHWAN HENARI: There are a couple of questions. The first question is actually from on rotator cuff's sorry, on track versus off track lesions. Could you please explain that again?
MUSTAFA RASHID: I haven't talked about that yet, but I will talk about that at the end. I've got some bonus slides if you really want to learn about on track. Off track, you won't get to in the phrases unless you're doing exceptionally well.
MUSTAFA RASHID: I did get asked it in the exam, but then again it's a shoulder session asking me and I'm a shoulder I'm a shoulder surgeon. So we got quite deep into that case. But I will talk about on track, off track at the end of the talk, I promise, if we've got time.
SHWAN HENARI: I think the question for me in the FRCS is if you have a first time dislocation or would you and you can't see any obvious abnormality on the X ray?
SHWAN HENARI: Would you say you would go for a CT scan to look for a Bony Bankart or would you wait?
MUSTAFA RASHID: And now they all get cross-sectional imaging so wherever that is of your choice, I would say the safe answer is probably an MRI first, because you will pick up a Bony Bankart with an MRI a lot of the time, it's just quantifying the amount of bone loss is not as accurate in MRI, but the answer to that is they're seen in the shoulder, upper limb trauma clinic within a couple of weeks,
MUSTAFA RASHID: the advice is to discard the sling as soon as the pain subsides. No restriction in mobilization, and they get cross-sectional imaging of whatever your preference is, most commonly an MRI to look for the associated pathology. And if they're under 25, they get offered surgery if their clinical features are in keeping with their radiographic findings and if they are over 25, you can try physiotherapy and reassess.
MUSTAFA RASHID: And the risk factors for pushing more towards surgical management after a first time dislocator are age, gender and contact sport.
SHWAN HENARI: So in the exam you would answer it in the way of younger patients you're more likely to offer surgical.
MUSTAFA RASHID: Yeah so, Yeah. So I would just play it safe and just say there are very good best guidelines on how to manage traumatic and serious stability.
MUSTAFA RASHID: That's what I would follow, which involves clinical and radiological assessment via cross sectional imaging in a specialist shoulder clinic with offering arthroscopic soft tissue stabilization if that's the primary lesion in young people under 25 the first time dislocator, that's what the national recommendations are and that's what most people's practice is, to be honest with you. That gone are the days of, oh, you've had only one dislocation,
MUSTAFA RASHID: well, go away and come back when you've had your second and then we'll stabilize you. Those days are gone. The only time you do that is in slightly older patients or patients that aren't particularly active they've just had a freak traumatic event, that's why they're dislocated.
SHWAN HENARI: OK, perfect answer. Thank you very much. If there's no other questions, we can move on.
MUSTAFA RASHID: Yeah, I think. Mehwali, did you ask about the radiographic signs or are you happy with that? I think we'll come back to that. So this is case one: It's a 21-year-old fit and active manual labourer who fell off a bicycle, he's now in the emergency department and he's got left shoulder pain
MUSTAFA RASHID: so this is quite common. This is the clinical radiograph you may get shown, this is just taken off Google. This is a very common picture, you see this a lot. Just take your time and just say what you see what you see. I'm not sure if you see my mouse here. Whenever you see this squaring off of the shoulder, just look at the opposite side,
MUSTAFA RASHID: that's what your normal shoulder contours are meant to look like. The most lateral part of a normal shoulder is your humeral head, your great tuberosity and the deltoid muscle. When you've dislocated anterior inferiorly, the most lateral part of your shoulder now becomes the lateral edge of the acromion and that's very visible here. Yeah so whenever you see that, it's almost certainly going to be an anterior dislocation.
MUSTAFA RASHID: OK so then you may go through your spiel of immediate assessment and get radiographs to confirm and you may get shown something like this. Don't get bogged down too much with this. This is an AP radiograph demonstrating the anterior dislocation of the glenohumeral joint with what looks like a Hill-Sachs lesion. I would then transfer the patient to the resuss department, request immediate procedural sedation and safely reduce the shoulder documenting neurovascular status before and after.
MUSTAFA RASHID: And then confirming the same radiological events and joint. Very simple, nothing too difficult about that. The top tips for this kind of case, try to progress quickly through the A&E management, you really want to get to talking about the pathology on imaging and how you're going to manage this patient in the clinic and the nuances of age, gender, time of dislocation, recurrence, all of that is where you really want to get to with this stage as quickly as you can.
MUSTAFA RASHID: The station can take many different routes. They could start off the same way and you and your friends may get different questions. It may focus on how you reduce it in A&E, it doesn't really matter how you do it you've just got to be able to describe how you do it and why it's and why you choose to do that and how you go about doing it. It may talk about a nerve injury, either pre or post reduction, and how are you going to manage that?
MUSTAFA RASHID: Again, keep it very simple. You're going to make an appropriate assessment, you're going to see them again in clinic and you're going to look for degenerative nerve lesion and then refer onwards to a nurse specialist as per the BOAST guidelines without delay. What happens when you fail to reduce it in A&E? That's where it could go, you know, you try, you try, and try again.
MUSTAFA RASHID: Your SHO tries, everyone tries, you can't get it in so what are you going to do and it's about how you progress to safely doing it. And if there's no vascular compromise, there is no immediate urgency. And if you don't have the skills to address the scenario in its entirety, then it's OK to wait. But actually the FRCS, they do expect you to be able to do a delta pectoral approach and reduce a dislocated locked dislocation.
MUSTAFA RASHID: So you can't wriggle out of it, you're going to have to talk about progressing to open reduction at some point. The only time where I would caveat that is if it's a fracture dislocation of an elderly four part fracture where actually there's a reasonable chance the patient may require a reverse shoulder replacement as the definitive management at the first operation.
MUSTAFA RASHID: And you're not a shoulder surgeon, you may need to discuss that, but you may need to talk about the principles anyway so, you still can't get out of talking about it, but you can at least mention that. I would personally not do this because I'm not a shoulder specialist because there's a reasonable chance this patient may require a reverse
MUSTAFA RASHID: blah blah, blah, but the principles are as follows. They may talk about the outpatient management in clinic. What kind of imaging, why, what lesions are you looking for? If it's someone who isn't a barn door or arthroscopic Bankart repair type patient, how are you going to actually manage them, what's your pathway for physio,
MUSTAFA RASHID: what are you going to ask the physio to work with? That's all kind of subtle and important things. Essentially what you're looking for is restoration of range of motion, strength, and ensuring that they understand how to regain a normal proprioception in the context of a dislocation. So that's all about core stability, tt's about scapular control,
MUSTAFA RASHID: we talked about that and then just refer back to the BESS guidelines, they're there to help you. And think of them like the BOAST guidelines, you know, if you talk about open fractures, you're not talking about the BOAST guidelines, then you'd probably miss the boat there. Same with this. You got anterior traumatic anterior instability in the shoulder,
MUSTAFA RASHID: just talk about the BESS guidelines. they're there to help you. So case number two, 23-year-old recreational rugby player, had a second dislocation four weeks ago, reduced in the emergency department. The first dislocation occurred whilst playing rugby 18 months ago. He works in an office, is fit and healthy, he plays rugby every other weekend and he's seen in the outpatient department with feeling of instability when he abducts and externally rotates, the classic at risk position at risk position of your shoulder.
MUSTAFA RASHID: You may get shown this, this is some rugby league player I found on Google. You had a dislocation and they may, I don't think they will, but they could show you something, some form of imaging that is trying to point you towards the fact they've lost glenoid bone. So that could be the other type of scenario that you may get because you need to understand that you can't just do a labral repair in this context,
MUSTAFA RASHID: it's highly likely that it will fail. You've got a male contact athlete with glenoid bone loss, they're really pushing to talk about bone loss in the context of instability. You don't need to know too much about it other than that, if you've lost bone put bone back. So always look for bone loss, commonly on the humeral head, but also on the glenoid.
MUSTAFA RASHID: There are some axial cuts that they may show you on radiographs where you'll see quite obvious rounding off of the anterior glenoid. They may show you a cross sectional axial of CT scans. They may show you a lot of things, but just always comment on the glenoid. If you if you get imaging just to see if there's a Bankart fracture there or just loss of glenoid bone, which often happens over time.
MUSTAFA RASHID: If it's unclear, get more imaging. MRI is probably the gold standard, but for bone loss, have a low threshold, for CT, it's easier to get, it's more accurate for quantifying the percentage of bone loss. You've got to remember, you know, 20% bone loss is only really about five or six millimeters in the glenoid, there are small amounts and and we know that CT is more accurate for bone than MRI.
MUSTAFA RASHID: If bone is lost, put bone back, and I would say the Open Latterjet is probably the gold standard in this country. Don't start talking about bone block procedures unless they specifically ask you. The Open Latterjet is something that you should be able to describe and describe how it works, what the principles of it are, and the anatomy of it. Look for pertinent risk factor recurrence. OK? Bone loss,
MUSTAFA RASHID: young male, contact athlete. And finally, case number three. This is the classic case that you often will get. 77-year-old nursing home resident with dementia, complaining of pain for the last two weeks to their carers. History of falls, hypertension TIA,
MUSTAFA RASHID: reasonable quality of life, only really needs assistance with preparing food and shopping and ambulates independently. There's a couple of nuances here, right? The dementia, nursing home, 77, OK? That's all relevant because what you really need to pick up in this kind of scenario is that the pain for the last two weeks is a red herring,
MUSTAFA RASHID: this could have been dislocated for months. And in fact, it has been dislocated for months until proven otherwise. So, the way you fail the scenario is you start hoicking on this little old lady's shoulder in A&E recuss, trying to reduce it, people often do. You will break her humerus if you do so.
MUSTAFA RASHID: So it's a chronic locked posterior dislocation until proven otherwise. OK? This is the X-ray they may show you, you may say this abnormal contouring of the proximal humeral head, it looks like a light bulb sign, I can see a Hill-Sachs lesion with a trough line sign and the glenoid fossa looks vacant. This is all in keeping with a possible locked posterior dislocation.
MUSTAFA RASHID: I would like to get another radiographic view to confirm this. They don't have any, but they may show you, they won't show you videos, but they may show you a single axial slice of a CT. And you can see this is here, the articular surface of the humeral head. That's the LT, that's the GT, the bicipital groove is just here and so this articular surface is meant to be here.
MUSTAFA RASHID: You can see, this is a locked posterior disclocation, and you'll have to believe me when I say to you, there isn't a lot of sclerosis here so this may be an acute CT scan, this is not the same patient, this is some patient off Radiopaedia. But you can see there's not a lot of chronic changes here so this may be more of an acute, but often what they'll show you something with a lot more sclerosis, a lot of calcifications, osteophytes, degenerative changes in the fossa,
MUSTAFA RASHID: these are all signs pointing towards a very chronic situation. If you're doing really well, they may ask you how you're going to manage this, and you need to basically talk about your assessment of how acute you think this is. If it is genuinely a few weeks and the CT scan does not show any chronic, sclerotic changes to the joint surfaces,
MUSTAFA RASHID: you may consider doing something called a modified McLachlan or a McLaughlin procedure. So the McLaughlin procedure was described, Aargh, I forget his first name. What was his name: McLaughlin, like 1950 and then like JBJS and he basically just did a subscap medialization compared to what it was. He took the sub scap off and then he put it in to where that reverse Hill-Sachs defect is OK, and it's basically like a remplissage slash subscap transfer to avoid that defect then falling back into the glenoid rim. A modified
MUSTAFA RASHID: McLaughlin is where you take an LT osteotomy, so you take the lesser tuberosity with the subscap and you then medialize that into the reverse Hill Sachs lesion and you're basically filling in that impaction fracture by taking a vascularized graft essentially, which is the subscap would be lesser tuberosity and you're fitting it into that defect.
MUSTAFA RASHID: So that's a modified McLaughlin. You can do other things in a 77-year-old if it's unstable, after doing your modified McLaughlin, you may choose to take it down and do a reverse. OK a reverse is a very powerful way of bailing out that scenario. But you don't want to be doing a reverse in a 50-year-old with this problem.
MUSTAFA RASHID: So if they're 50, you're more likely to do a modified McLaughlin and try and stabilize it. If it doesn't stabilize after a modified McLaughlin, then you may even choose to do a bone block, not at the same time necessarily, but that's really getting into level eight questioning there. But essentially, if they're younger, you're more likely to try and salvage the head, unless it's incredibly chronic, then you're going to have to do a reverse.
MUSTAFA RASHID: Assume chronic until proven otherwise, the top tip for this scenario, it's really quite key. Bringing out the nuance of decision making, explain your rationale. OK? There's lots of different things you can do, the commonest is a modified McLaughlin. You can do bone graft if it's really acute, and you can treat it like an acute fracture,
MUSTAFA RASHID: you can elevate the fragment and fill some bone void filler behind it. If it's an older patient with chronic changes, just your bailout is in reverse. It's not uncommon in some patients like this to do nothing, just to do nothing if they're super high risk for surgery, and that they've got a bit of aching, but not in agony all the time,
MUSTAFA RASHID: and their risk for having a perioperative complication is really high, then you can leave them. They'll get very poor function, but the pain usually subsides. So modified McLaughlin bone graft reverse are the main options, really. The reverse is a safe option in those over 65, but it's not without risk. It's technically a very difficult reverse to do
MUSTAFA RASHID: and it's not uncommon that that reverse will become unstable if it's not done correctly and tensioned properly. Thank you very much.
SHWAN HENARI: Thank you. A few questions.
MUSTAFA RASHID: Abbott asked me to remind everyone about the feedback.
MUSTAFA RASHID: Be grateful you can fill in the feedback form, but let's move on to questions for the time being. Shwan, have you got any?
SHWAN HENARI: So, if you remember, there was, we will come back to that on track off track. Yep yeah, we'll come back to that in a second. In terms of anesthesia for reduction, would you consider local or intra articular is described?
MUSTAFA RASHID: It is described. You can also get a regional block and do a reduction that way. We've done that at Wrightington a few times. It's not a common thing so I bet you don't start coming out with fringe answers in your FRCS. Stick with mainstream is my advice and the mainstream is appropriate sedation in the emergency department recuss.
MUSTAFA RASHID: If that's not available, or the patient's risk factors are too high, get anesthetic support and get a general anesthetic and do it under muscle relaxation.
SHWAN HENARI: Sorry, so you, so this provokes an exam from your examiners raised eyebrows and it provokes it wakes the bear which is what you're going to do let (sleeping dogs lie).
MUSTAFA RASHID: Don't start saying things that perks them up.
SHWAN HENARI: automatically, when someone says that to me, I'm going to ask a couple of questions. Your anatomies disrupted, how are you going to find your place to inject? Number one. Number two, what happens if that fails? Number three, what if what local anesthetic are you going to use? I'm going to be really grilling into your local anesthetic.
SHWAN HENARI: And we know that some papers have shown that there may be a risk with high levels of local anesthetic or cartilage damage so then that brings up that question as well so I'm not saying you shouldn't give local anesthetic into a joint, like knee surgeons are doing arthroscopy as often do, but you have to be aware that there are risks associated with what you're doing as well.
SHWAN HENARI: And the fact that you bring it up means you're going to be grilled really down to the minutia in this topic straightaway because it's unusual and it means you're provoking, They're now wondering if you're a safe surgeon or not.
MUSTAFA RASHID: Yep I agree. The other question is about how do you reduce a locked posterior dislocation? It's a delta pectoral approach.
MUSTAFA RASHID: It's often very difficult. You often have to have the patient fully relaxed. The anatomy is distorted, obviously, on the way in. The key really is, be patient, get a Hohmann retractor in between the humeral head and the glenoid and just walk it off the glenoid, it can be very difficult to do. If you have an anterior, locked anterior dislocation, the commonest thing that people do is they struggle to fish the head out and they wrap their instruments around the brachial plexus because it's really not that far away.
MUSTAFA RASHID: If that's, if you're struggling to do that, the safest thing is to take the coracoid down and so you can make more space for yourself anteriorly. But a locked posterior dislocation is a delta pectoral approach, don't go through the back, it's incredibly difficult. There's another question from Syed about how much bone loss is fixable. There's no right answer for this.
MUSTAFA RASHID: But if your lesser tuberosity is smaller than the bone loss that you've got, then you're in a bit of trouble, OK, then it'll be hard to stabilize that shoulder in a posterior bone loss, large reverse Hill-Sachs context. In acute scenarios in young people, the Americans love allograft and there are even these things called hemi-caps that you can put in, which basically are metal caps that will fit onto the different sized defects of the Hill-Sachs, again, not common UK practice,
MUSTAFA RASHID: don't start talking about that. If it's really acute, you can treat it like an impaction fracture, elevate it like you would a tibial plateau and bone graft it behind and you can do that with or without taking down the sub-scap, depending on if you can access it from the interval or not. You're not going to get asked that to be honest so. And then I'm just going to talk briefly about some bonus marks here. Can you still see my slides OK?
SHWAN HENARI: Yep, just a heads up. The bonus marks don't count if you don't get the basics right, guys.
MUSTAFA RASHID: So 100%, 100%, you not going to volunteer this but if you get asked this, you're pretty much past this stage. OK so if the examiner asks you, would you ever consider an external rotation study, what they're basically asking you is whether you know the evidence behind this.
MUSTAFA RASHID: And so basically HJA and Foys, another one of these famous shoulder surgeons who came out with this paper quite a long time ago, now, nearly 20 years ago, where he had predominantly Japanese students who had a traumatic first time anterior dislocation and he put them in this contraption, which is a custom external rotation immobilizer. And he basically found the rate of recurrence in his RCT was lower in the ER sling versus the standard sling and internal rotation
MUSTAFA RASHID: and the idea is, an external rotation, the inferior capsule is slightly more taut and so it reduces the labrum closer to the footprint of the glenoid rim and therefore it may heal in that better position and be more stable. The annoying thing about this, even though this is fantastic, there are two other RCT's that came out from North America I think, maybe one was from Australia that basically did not replicate his results.
MUSTAFA RASHID: And when I asked about him Professor ? I've actually been to Japan to visit another shoulder surgeon out there, what was abundantly clear is they have no issue with compliance, right? If the surgeon says you need to be an ER sling all the time, they will be in an ER sling all the time. And the other thing they said to me, because you won't remember, most of my population were students who worked in the big University town
MUSTAFA RASHID: and he said, you know, most of the time they're at a desk and so they're not manual laborers and they're not going to discard their sling and get back to work straight away. And so just say in the exam, if you asked about this, it's controversial, it's not commonly employed, and there was one study in Japan that suggested it's useful, but it hasn't ever been replicated and so it's not something I would consider.
MUSTAFA RASHID: And if you've ever tried to put anyone on ER, immobilizer yourself, they'll take off within a week. The patients hate this more than anything else. All right? The next thing is about Hill-Sachs. You may get asked, how do you measure a Hill-Sachs? You could use this method, the circle method, you could talk about the width of the Hill-Sachs, but what they're really trying to get at, if you're really going for the eight, if you've nailed everything else,
MUSTAFA RASHID: and they're asking you, do you know any other ways of quantifying whether a Hill-Sachs is relevant or not in the context of this dislocated shoulder, they're basically asking you if you understand between this concept of the glenoid track. Now the glenoid track basically came from again Professor Etoy [?] with an Italian surgeon called Giovanni Giacomo, Giacomo, I think his name is, where they basically looked at where the glenoid tracks on the humerus in the functional range of motion arc.
MUSTAFA RASHID: So they put die on cadavers onto the glenoid and they then cycled them through a normal glenohumeral joint and then they tracked on the humerus where the glenoid was articulated. They then created Hill-Sachs lesions and bone loss on the glenoid side to try and determine this concept of the glenoid track. All you really need to know is there are two measurements that you make. They described it on CT, John Turkish and Matt Provencher, I believe have validated it for MRI.
MUSTAFA RASHID: But what you basically need to measure is two measurements. One of them is called the Hill Sachs interval, which is the Hill-Sachs defect, plus the bony bridge up until the rotator cuff attachment and that's a number. You then need to measure the glenoid track, now the glenoid track on the cadaver specimen was 83% of the maximum glenoid width. But when you've got bone loss, the massive glenoid width is your perfect circle in the lower 2/3 of your glenoid, minus whatever glenoid bone you've got. That gives you your glenoid track.
MUSTAFA RASHID: 83% of that is your total glenoid tract. Now, the way I remember this, I got taught this by someone at the American Academy, which kind of makes sense, is if you're off track, think about it like a Formula One race car. If you're off track, you've crashed and you're likely to be unstable and therefore have to address the bone loss. OK? And off track is bad.
MUSTAFA RASHID: If you're off track, if your Hill-Sachs interval is larger than your glenoid track. You're on track, which is good, your race car is on the track, it hasn't crashed and that's because your Hill-Sachs interval is smaller than your glenoid track. Think of it like I don't know, a really wide race car and a really small track.
MUSTAFA RASHID: Yeah, if you're going around the bend, if your race is wider than the tarmac, you might crash off the road, that's off track. If your race car is narrower than the width of the bend, you're going to remain on the tarmac and you're on track and therefore you don't need to address the bone loss. This has been validated as being a pretty good indicator of who fails following purely soft tissue surgery.
MUSTAFA RASHID: If you get asked this in the FRCS for the station, you might be on for a gold medal so don't worry too much about the side.
SHWAN HENARI: Perfect. Thank you. Good feedback from one of our mentors who loves the concept of the race car off track. Thank you, everybody.
SHWAN HENARI: Once again, just thank you, Mustafa, that was an excellent talk, really well laid out and comprehensive and you made it really easy for everyone to understand.
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