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Orthopaedic Study Guide Series
Gazi Huri
Nikolaos K. Paschos Editors
The Shoulder
Series editors
Nikolaos K. Paschos
Department of Orthopedic Surgery
Division of Sports Medicine
Boston Children’s Hospital
Harvard Medical School
Boston, MA, USA
George Bentley
Royal National Orthopaedic Hospital
Stanmore, United Kingdom
Orthopaedics has many different specialisations such as trauma, spine, sports
medicine, arthroplasty, oncology, paediatric orthopaedics, hand surgery and
microsurgery to name just a few. This means that residents preparing for their
exams have a broad field to study and to remember. In addition, orthopaedics
is a surgical specialty, thus knowledge of orthopaedic techniques is necessary
and is tested during these exams. To cover all these fields and aspects of
orthopaedics, this book series has volumes dedicated to each study area and
provides a guide for all orthopaedic residents in preparation for residency and
fellowship exams.
More information about this series at http://www.springer.com/series/13489

Gazi Huri • Nikolaos K. Paschos
Editors
The Shoulder
Editors
Gazi Huri Nikolaos K. Paschos
Orthopaedics and Traumatology Department of Orthopedic Surgery
Department Division of Sports Medicine
Hacettepe University Boston Children’s Hospital
Ankara Harvard Medical School
Turkey Boston, MA
USA
ISSN 2520-1115 ISSN 2520-1123 (electronic)

ISBN 978-3-319-51977-7 ISBN 978-3-319-51979-1 (eBook)
DOI 10.1007/978-3-319-51979-1
Library of Congress Control Number: 2017946755
© Springer International Publishing AG 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my daughter Alin Defne, my wife Pınar, and to the peace
of the world
Gazi Huri, M.D.
To my teachers that dedicated their life to medical education

To my orthopedic residents that are always an inspiration to
strive for excellence
To my family for their endless support all these years
Nikolaos K. Paschos
Series Preface
The vision behind the conception of “Orthopaedic Study Guide Series” was
to create a book series that will cover the need of effective and focused revi-
sion study for all young orthopedic surgeons. This is a study guide that is the
spiritual child of FORTE, the Federation of Orthopedic Trainees in Europe.
The main goal is to highlight some key issues for exam and stimulate
young colleagues for additional study. Following these principles, this study
guide was built with a unique format incorporating text with concise informa-
tion, review questions, key points, description of case studies, mnemonic
tricks, and references/suggestions for additional study.
The editors would like to thank FORTE for their continuous support in this
project, and Springer for their commitment towards the study guide series.
More importantly, we would like to thank the authors and editors for their
substantial contribution to this series and their dedication towards orthopedic
education and training.
vii
Contributor Preface I
It is an honor and a pleasure for me to write the introduction to the inaugural

edition of FORTE (Federation of Orthopaedics Trainees in Europe) Book
series. Dr. Huri was a research fellow at our institution in the Division of
Shoulder and Elbow Surgery, and despite being a brilliant person, a hard
worker, and a good friend, he always seemed to understand and empathize
with all of the trainees at our institution. He was a master at teaching and
helping the students, residents, and clinical fellows conceptualize and under-
stand the shoulder from the basic anatomy, to the biomechanics, to the exami-
nation, the interpretation of radiographs, the treatment options, and how to
weigh what was best for the patient. He was always thinking of ways to make
knowledge of shoulder conditions and treatments easier to understand to be
applied in a practical way to shoulder practice. The result of that interest and
awareness was the creation of the International Shoulder Club, which was
designed to make it easier for those interested in shoulders to have an organi-
zation which would appeal to them. This organization was aimed at the
trainee but also the younger generation of providers with an interest in
shoulders.
The second product of his interest in shoulders and in helping educate
other health care providers was this book. Dr. Huri has recruited an amazing
group of contributors who not only have experience in shoulders but are close
enough to their training to understand what is important to know at every
level. The result is a book of value not only to people new to the shoulder
challenges but also to the seasoned veteran who wishes to have a quick and
handy guide to the up-to-date concepts and knowledge of shoulder conditions
and treatment.
The book is very concise and well organized by topic. Unlike many shoul-
der books this book gives solid advice and guidance about the nonoperative
treatment of most shoulder conditions. There is enough information here for
the novice and the expert in a concise and easy-to-understand format. In the
theme mentioned above of thoughtfulness about those training in shoulder
surgery or in orthopedics in general, each chapter is followed by multiple
choice type questions to assist in preparing for boards or for the gruffy attend-
ing at your throat.
I can recommend this book without any reservation and it should become
a best seller for those within orthopedics and in shoulders particularly.
Baltimore, MD, USA Edward G. McFarland
ix
Contributor Preface II
Over the past decade, the field of orthopedic surgery has become significantly
competitive from the perspective of orthopedics residents. Most residents are
interested in pursuing a career in orthopedic surgery and become a good sur-
geon. The FORTE book series is designed to provide orthopedics residents
and trainees a resource to enable them to be more proactive about their intra-
operative learning. This book offers a roadmap for the most common ortho-
pedic operative procedures in shoulder surgery. Each chapter presents the
basic science, anatomy, biomechanical features of shoulder, principles of
physical examination, and an algorithmic approach to shoulder disorders.
This book covers the contents of what an orthopedics and traumatology
resident need to know about current trends and concepts about the shoulder.
I hope that this book assists all the trainees in optimally improving their
shoulder knowledge and increase the success in board exams.
Thank you very much indeed to Dr. Gazi Huri for his outstanding effort in
editing this book and inviting me to participate in this nice work.
Ankara, Turkey Mahmut Nedim Doral
xi
Editor’s Preface
The medical field is continuously changing and growing—aiming to perfect

treatments and create better experiences for patients. Today, there are simple
procedures for conditions which were very challenging to treat years before.
Like other focuses of medicine, orthopedics has also changed for a great deal
over the years and has become an area which treats an endless array of condi-
tions. A hundred years ago, orthopedic surgery was in its infancy and ortho-
pedic residency did not even exist. Orthopedics practice was learned in a
traditional master and journeyman relationship, or most of the time, just by
trial and error. But today, we have several modern and rapid ways of learning
and practice. In addition to several educational materials in orthopedics, I
believe that this book will be a good reference source that would provide the
knowledge base needed for competent orthopedics practice. This book covers
the contents of what an orthopedics and traumatology resident need to know
with a primary focus on shoulder.
This book is one of the educational projects of Federation of Orthopaedics
Trainees in Europe (FORTE) with outstanding international efforts under-
neath. In this book, we aimed to create a reference which is based on European
Education Platform (EEP) core curriculum for preparing for European Board
of Orthopaedics and Traumatology (EBOT) Exam. Based on that, this book
contains 30 chapters discussed by outstanding experts in the shoulder field.
Among these experts, I would like to express my deepest appreciation to
Prof. Mahmut N. Doral, Prof. Edward G. McFarland, Prof. Ofer Levy, Prof.
Young L. Moon, Prof. Uma Srikumaran, Dr. Ehud Rath, Dr. Filippo Familiari,
and all other valuable contributors from all over the world such as the USA,
Turkey, the United Kingdom, Israel, Italy, Greece, France, and Korea.
Furthermore I would like to thank my friends Dr. Enis Guryel, Dr. Bram
Hentenaar, Dr. Nikolaos Paschos, and Dr. Joao Vide as the FORTE presidents
for their great motivation and support. Also I would like to convey my sincere
thanks to Ms. Liz Pope for her great patience and encouragement during the
project. It was a great pleasure for me to collaborate with her in that long trip.
Finally, I would like to thank my biggest supporters, my daughter Alin
Defne and my wife Pınar. Thank you for understanding me even when I
worked till mornings and unable to spend time with you. Thank you for lov-
ing me. Thank you for being in my life.
Enjoy the book!
Yours sincerely
Gazi Huri
xiii
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Contents
Part I Basic Science
1 Shoulder Anatomy �� 3

Nickolas G. Garbis
2 Surgical Approaches to the Shoulder�� 15
Nickolas G. Garbis
3 Shoulder Biomechanics �� 25
Marcheggiani Muccioli Giulio Maria, Lullini Giada,
Grassi Alberto, Roberti di Sarsina Tommaso, Raggi Federico,
Carbone Giuseppe, and Zaffagnini Stefano
Part II Clinical Evaluation
4 History�� 37
Edward G. McFarland
5 Physical Evaluation�� 43
Edward G. McFarland, Kyubo Choi, Seyedali R. Ghasemi,
and Alex Bitzer
6 Assessing Outcomes �� 67
Jacob Joseph and Edward G. McFarland
Part III Investigations
7 Three-Dimensional Visualization in Clinical

Shoulder Practice �� 77
Young Lae Moon
Part IV Shoulder Trauma
8 Clavicle Fractures�� 91
Filippo Familiari, Gazi Huri, Olimpio Galasso,
Giorgio Gasparini, and Mahmut Nedim Doral
xv
xvi Contents
9 Proximal Humerus Fractures �� 101

Cem Zeki Esenyel
10 Reverse Shoulder Arthroplasty for 3-Part
and 4-Part Proximal Humerus Fractures�� 115
E. Boyer, G. Menu, R. Saadnia, F. Loisel, J. Uhring, A. Adam,
S. Rochet, P. Clappaz, E. Baudouin, T. Lascar, and L. Obert
11 Dislocations and Fracture Dislocations
of the Shoulder Girdle �� 127
Danny Ryan and Mustafa Rashid
12 Scapula and Glenoid Fractures�� 141
Egemen Turhan, Mehmet Kaymakoglu, Gazi Huri,
and Mahmut Nedim Doral
Part V Specific Shoulder Disorders
13 Inflammatory Arthropathy of the Shoulder�� 151

Kadir Büyükdoğan, Gazi Huri, Ashnaa Rao,
and Mahmut Nedim Doral
14 Joint Sepsis �� 159
Mesut Atabek, Gazi Huri, and Ugur Gonc
15 Avascular Necrosis �� 175
Gazi Huri, Mehmet Kaymakoğlu, Yusuf Bora Bozduman,
Ersin Mutlu, and Mahmut N. Doral
16 Soft Tissue Disorders �� 185
Dogac Karaguven and Osman Orman
Part VI Non-operative Management of Shoulder Disorders
17 Splints and Orthoses�� 205

Nilgün Bek
18 Shoulder Rehabilitation�� 215
Irem Duzgun, Leyla Sumeyye Eraslan, Taha Ibrahim Yildiz,
and Serdar Demirci
19 Injections�� 257
Filippo Familiari, Gazi Huri, Olimpio Galasso,
Giorgio Gasparini, and Mahmut Nedim Doral
Part VII Operative Management of Shoulder Disorders
20 Arthroscopic Positioning: Beach Chair Versus Lateral �� 265

Kelly G. Kilcoyne and Uma Srikumaran
21 Anatomic Shoulder Arthroplasty �� 273
Tsvieli Oren, Atoun Ehud, and Ofer Levy
Contents xvii
22 Reverse Shoulder Arthroplasty�� 293

Matthew Baker, Kyubo Choi, Seyedali R. Ghasemi,
and Edward G. McFarland
23 Resection Arthroplasty�� 351
Ulunay Kanatli, M. Baybars Ataoğlu,
and Mustafa Özer
24 Revısıon Shoulder Arthroplasty �� 361
Ulunay Kanatlı, M. Baybars Ataoğlu,
and Mehmet Cetinkaya
25 Shoulder Arthrodesis�� 373
Ehud Atoun, Zachary T. Sharfman, Ehud Rath,
and Ofer Levy
26 Anatomy, Assesment, and Surgery of the Biceps Tendon�� 381
Zachary T. Sharfman, Ran Atzmon, Eyal Amar,
and Ehud Rath
27 Rotator Cuff Surgery�� 393
Gazi Huri and Saygin Kamaci
28 Surgical Management of Stiff Shoulder�� 403
Ahmet Yildirim and Mustafa Özer
29 Surgical Management of Shoulder Instabilities�� 415
Sercan Akpinar and Aydin Budeyri
Index�� 443
Editors’ Biographies
Gazi Huri, M.D. is an Associate Professor

at Hacettepe University School of Medicine
Department of Orthopaedics and Trauma
tology, Ankara, Turkey.
He did his residency at Hacettepe
University Orthopaedics and Traumatology
Department between 2003 and 2008.
Consequently he has worked at Johns
Hopkins University School of Medicine,
Department of Orthopaedics and
Traumatology, Division of Sport Medicine,
Baltimore, MD, USA, as a fellow “Shoulder
Surgeon” between 2012 and 2014.
He has taken several positions in interna-
tional professional associations and organizations. He is the Turkey represen-
tative of the European Board of Orthopaedics and Traumatology (EBOT),
which is the most qualified organization on Orthopaedics Education in
Europe. In addition he was the former president (2014–2015) of Federation
of Orthopaedics Trainees in Europe (FORTE) which represents the young
orthopaedics surgeon in Europe and currently he is still keeping the educa-
tional committee “President” position in the same organization.
He has an international patent (USA, European PO, Japan, and Turkey)
about orthopedics and traumatology which is awarded “the Best Patent
Award” and “Best Academic Invention” by the International Federation of
Inventors’ Associations (IFIA) during the International Inventions Fair 2016.
He has more than ten awards for his academic researches and more than 50
papers in international books and journals as well. He is one of the coordina-
tors of the European Union ERASMUS Plus project titled as ESTRO/
European School for Training in Orthopaedics.
He is married and has a child.
xix
xx Editors’ Biographies
Nikolaos K. Paschos
Dr. Paschos’s interdisciplinary background
spans the fields of orthopedics, sports medi-
cine, emergency medicine, biomechanics,
and regenerative medicine. He is committed
for continuous education and training
towards improving quality of life of patients.
Originally from Greece, Dr. Paschos com-
pleted his medical education and residency
training at the University of Ioannina, and
after spending some time in the UK and
Ireland he moved to the USA. He holds a Ph.D. in biomechanics and tissue
engineering, and he has worked at the University of California Davis. He is
currently working in the Department of Orthopedic Surgery, Division of
Sports Medicine at the Boston Children’s Hospital, Harvard Medical School.
Since 2010, he serves in the Executive Board of Directors of FORTE
(Federation of Orthopaedic Trainees in Europe) where he served as the
President of FORTE from 2013 to 2014. During that time he initiated the
process that led to the birth of the Orthopaedic Study Guide Series.
Contributors
Antoine Adam, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,

Nano medicine Research, CHRU Besancon, University of Bourgogne—
Franche Comte, Besancon, France
Sercan Akpinar, M.D. Department of Orthopaedics and Traumatology,
Medline Hospital, Adana, Turkey
Grassi Alberto, M.D. Istituto Ortopedico Rizzoli, University of Bologna,
Bologna, Italy
Mesut Atabek, M.D. Orthopaedics and Traumatology Division,
Liv Hospital, Ankara, Turkey
M. Baybars Ataoğlu, M.D. Faculty of Medicine, Department of
Orthopaedics and Traumatology, Gazi University, Ankara, Turkey
Ran Atzmon, M.D. Department of Orthopaedic Surgery, Assaf Harofe
Medical Center and the Sackler Faculty of Medicine, Tzrifin, Israel
Matthew Baker, M.D. Department of Orthopaedic Surgery, The Johns
Hopkins University, Lutherville, MD, USA
Emmanuel Baudouin, M.D. Centre Hospitalier de Chambéry, Place Lucien
Biset, Chambéry, France
Nilgün Bek, P.T., Ph.D. Department of Physiotherapy and Rehabilitation,
Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
Alex Bitzer, M.D. Division of Shoulder Surgery, Department of Orthopaedic
Surgery, The Johns Hopkins University, Baltimore, MD, USA
Etienne Boyer Orthopedic, Traumatology, and Hand Surgery Unit, Nano
medicine Research, CHRU Besancon, University of Bourgogne – Franche
Comte, Besancon, France
Yusuf Bora Bozduman, M.D. Orthopaedics and Traumatology Department,
Hacettepe University School of Medicine, Ankara, Turkey
Aydin Budeyri, M.D. Department of Orthopaedics and Traumatology,
SANKO University, Faculty of Medicine, Gaziantep, Turkey
Kadir Büyükdoğan, M.D. Steadman Philippon Research Institute, Vail,
Colorado, USA
xxi
xxii Contributors
Kyubo Choi, M.D. Division of Shoulder Surgery, Department of Orthopaedic

Surgery, The Johns Hopkins University, Lutherville, MD, USA
Pascal Clappaz, M.D. Clinique Convert, Bourg-en-Bresse, France
Serdar Demirci, P.T., M.Sc. Department of Physiotherapy and
Rehabilitation, Hacettepe University, Ankara, Turkey
Mahmut Nedim Doral, M.D. Department of Orthopaedics and
Traumatology, Hacettepe University, Ankara, Turkey
Irem Duzgun, P.T., Ph.D. Department of Physiotherapy and Rehabilitation,
Hacettepe University, Ankara, Turkey
Atoun Ehud, M.D. Faculty of Health Science, Ben Gurion University,
Barzilai Medical Center Campus, Ashkelon, Israel
Leyla Sumeyye Eraslan, P.T., M.Sc. Department of Physiotherapy and
Cem Zeki Esenyel, M.D. Department of Orthopaedic Surgery, Giresun
University Medical Faculty, Giresun, Turkey
Filippo Familiari, M.D. Department of Orthopaedic and Trauma Surgery,
Magna Græcia University, Catanzaro, Italy
Raggi Federico, M.D. Istituto Ortopedico Rizzoli, University of Bologna,
Bologna, Italy
Olimpio Galasso, M.D. Department of Orthopaedic and Trauma Surgery,
Nickolas G. Garbis, M.D. Loyola University Medical, Maywood, IL, USA
Giorgio Gasparini, M.D. Department of Orthopaedic and Trauma Surgery,
Seyedali R. Ghasemi, M.D. Division of Shoulder Surgery, Department of
Orthopaedic Surgery, The Johns Hopkins University, Lutherville, MD, USA
Lullini Giada, M.D. Istituto Ortopedico Rizzoli, University of Bologna,
Bologna, Italy
Marcheggiani Muccioli Giulio Maria, M.D., Ph.D. Istituto Ortopedico
Rizzoli, University of Bologna, Bologna, Italy
Carbone Giuseppe, M.D. Istituto Ortopedico Rizzoli, University of
Bologna, Bologna, Italy
Ugur Gonc, M.D. Orthopaedics and Traumatology Division, Liv Hospital,
Ankara, Turkey
Gazi Huri, M.D. Department of Orthopaedics and Traumatology, School of
Medicine, Hacettepe University, Ankara, Turkey
Jacob Joseph, B.A. Division of Shoulder Surgery, Department of
Contributors xxiii
Saygin Kamaci, M.D. Department of Orthopaedic Surgery, University of

Louisville Hospital, Kentucky, USA
Ulunay Kanatlı, M.D. Faculty of Medicine, Department of Orthopaedics
and Traumatology, Gazi University, Ankara, Turkey
Dogac Karaguven, M.D. Department of Orthopaedics and Traumatology,
Ufuk University, Ankara, Turkey
Mehmet Kaymakoğlu, M.D. Department of Orthopaedics and
Traumatology, School of Medicine, Hacettepe University, Ankara, Turkey
Kelly G. Kilcoyne, M.D. Johns Hopkins Orthopaedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
T. Lascar, M.D. Centre Hospitalier Princesse-Grace, Monaco, France
Ofer Levy, M.D., M.Ch.(Orth.), F.R.C.S. Shoulder and Elbow Centre
Reading Shoulder Unit, Berkshire Independent Hospital, Reading, UK
François Loisel, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,
Nano medicine Research, CHRU Besancon, University of Bourgogne –
Edward G. McFarland, M.D. Division of Shoulder Surgery, Department of
Gauthier Menu Orthopedic, Traumatology, and Hand Surgery Unit, Nano
medicine Research, CHRU Besancon, University of Bourgogne – Franche
Comte, Besancon, France
Young Lee Moon, M.D. 3D Medical Application Work Group, IEEE-SA,
Milano, Italy
3D Printing Work Group, ISO-TC 261, Berlin, Germany
American Shoulder and Elbow Surgeons, San Diego, CA, USA
Orthopaedic Department, Chosun University Medical Research Center,
Chosun University Hospital, Gwangju, South Korea
Ersin Mutlu, M.D. Orthopaedics and Traumatology Department, Hacettepe
University School of Medicine, Ankara, Turkey
Laurent Obert, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,
Tsvieli Oren, M.D. Ma’ayanei Hayeshua Medical Center, Bnei-Brak, Israel
Osman Orman, M.D. Orthopaedic and Traumatology/Hand Surgery,
Baltalimani Metin Sabancı Bone and Joint Diseases Education and Research
Hospital, Istanbul, Turkey
Mustafa Özer, M.D. Meram Medical Faculty, Department of Orthopaedics
and Traumatology, Necmettin Erbakan University Medical School, Konya,
Turkey
xxiv Contributors
Ashnaa Rao, M.D. Johns Hopkins School of Medicine, Baltimore,

Maryland, USA
Mustafa Rashid, MB, ChB, MRCS, M.Sc. Nuffield Department of
Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS),
Oxford, UK
Ehud Rath, M.D. Department of Orthopaedic Surgery, Tel Aviv Soursky
Medical Center and the Sackler Faculty of Medicine at Tel Aviv University,
Tel Aviv, Israel
Severin Rochet, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,
Danny Ryan, MA, MB, BChir (Cantab), PGCME, FRSA,
MRCSEng Trauma and Orthopaedic Surgery, Gloucestershire Royal
Hospital, Gloucester, UK
Rachid Saadnia, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,
Roberti di Sarsina Tommaso, M.D. Istituto Ortopedico Rizzoli, University
of Bologna, Bologna, Italy
Zachary T. Sharfman, M.D. Department of Orthopaedic Surgery, Tel Aviv
Soursky Medical Center and the Sackler Faculty of Medicine at Tel Aviv
University, Tel Aviv, Israel
Uma Srikumaran, M.D., M.B.A. Johns Hopkins Orthopaedic Surgery,
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Zaffagnini Stefano, M.D. Istituto Ortopedico Rizzoli, University of
Bologna, Bologna, Italy
Julien Uhring, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,
Ahmet Yildirim, M.D. Department of Orthopaedics and Traumatology,
Selcuk University Medical School, Konya, Turkey
Taha Ibrahim Yildiz, P.T., M.Sc. Department of Physiotherapy and
Part I
Basic Science
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Shoulder Anatomy
1
Nickolas G. Garbis
The shoulder is a complex joint that is essential Sternum

to daily function. It serves as the connection of
the axial skeleton to the upper extremity. It has an The sternum is derived from the Greek word
essential function in positioning the upper στέρνον which means chest. It serves as the connec-
extremity in space, to allow us to interact with the tion point of the appendicular skeleton to the axial
environment, and to manipulate our surround- skeleton [1]. The sternum is composed of three
ings. In this chapter, we will present an overview parts: the manubrium (Latin: handle), the body, and
of the basic anatomy of the shoulder the xiphoid process. The sternum at its most cepha-
lad portion has a notch which is a depression between
the two sternoclavicular joints [2]. The sternocla-
Bones and Joints vicular articulation consists of shallow notches at the
superolateral corners of the manubrium that articu-
There are four bones which comprise the shoul- late with the medial ends of the clavicles (Fig. 1.1).
der girdle. The sternum, the clavicle, the scap- The manubrium and body also serve as the insertion
ula, and the humerus. Going over the specifics point of the costal cartilages for ribs 1–7. While the
of these individual bones will assist in under- majority of orthopedic surgeons will not perform
standing the relationships between them and any surgical procedures on the sternoclavicular joint,
the rest of the body. In addition, there are sev- it is important to understand it’s role in the biome-
eral articulations considered when evaluating chanics of shoulder motion.
the shoulder girdle. These are the sternoclavic-
ular (SC) joint, acromioclavicular (AC) joint,
and the glenohumeral joint. Although not tech-
Clavicle
nically “joints,” we also take into consideration
certain articulations or potential spaces, namely
The clavicle is a curved bone that spans from the
the subacromial space and the scapulothoracic
sternum medially to the acromion laterally. It has
bursa.
a flattened shape near the lateral third but a con-
vex shape medially [2]. It is the first bone in the
body which begins to ossifymm in utero at
5 weeks of life. The medial epiphysis is also the
N.G. Garbis, M.D.
last bone to fuse at age 23–25 [3]. At the sternal
Loyola University Medical Center,
Maywood, IL, USA end, the clavicle is approximately 23 mm × 22 mm
e-mail: [email protected] in cross section, 12 mm × 12 mm in the diaphy-
© Springer International Publishing AG 2017 3

G. Huri, N.K. Paschos (eds.), The Shoulder, Orthopaedic Study Guide Series,
DOI 10.1007/978-3-319-51979-1_1
4 N.G. Garbis
Fig. 1.1 Diagram of

the sternoclavicular
joint [36]
a b
Fig. 1.2 Gross anatomy of the coracoclavicularligaments (a) Anteriorview. (b) Anteriormedialview. CP coracoid pro-
cess, TL transverse ligament, SSN suprascapular nerve, CAL coracoacromial ligament [37] (Chapter 17, Yon-Sik Yoo)
sis, and 21 mm × 11 mm at the lateral end [4]. the anteroposterior direction. The primary
The clavicle is stabilized by the acromioclavicu- restraint provided by the conoid and trapezoid
lar and coracoclavicular (trapezoid and conoid) ligaments is in the craniocaudal direction [5].
ligaments (Fig. 1.2). The primary restraint pro- The clavicle acts as a strut that supports the
vided by the acromioclavicular ligaments is in arm for activities that are performed away from
1 Shoulder Anatomy 5
the body. It also serves as protection for underly-

ing neurovascular structures [6], and potentially
as a mechanical advantage for the myofascial
sleeve surrounding it [7].
Scapula
The scapula is a flat triangular bone with multiple

prominences. It acts as a mobile point of fixation
for several of the upper extremity stabilizing
muscles. The scapula is curved to articulate over
the rib cage. It has a prominent spine posteriorly
(Fig. 1.3) to serve as the division between the
supraspinatus and infraspinatus fossae. In addi-
tion, the coracoid projects anteriorly and is an
important landmark in surgical anatomy (some-
times called the “lighthouse of the shoulder”) [8]. Fig. 1.4 Anterior view of a left scapula
The conjoined tendon of the coracobrachialis and
short head of the biceps take their origin off the into the glenoid fossa. The glenoid anatomy can
coracoid. In addition, the coracoid serves as the be variable but the version usually ranges between
insertion site of the pectoralis minor tendon 9.5° of anteversion to 10.5° of retroversion [9].
(Fig. 1.4). The coracoclavicular and coracoacro- Mean glenoid inclination is approximately 4° of
mial ligaments also attach to the coracoid. The superior tilt [10]. The same study reported an
acromion is one of the more easily palpable average glenoid size of 27.8 mm × 37.5 mm in
prominences of the scapula, and serves as the men, and 23.6 mm × 32.6 mm in women.
connection point of the clavicle to the scapula
and also serves as the origin of the deltoid mus-
cle. Towards the lateral end of the scapula, the Humerus
bone flares into the glenoid neck and terminates
The humerus is the extension of the shoulder
joint that allows us to position our distal extrem-
ity in space. The humeral head is the ovoidproxi-
mal end of the humerus that articulates with the
glenoid. Its average radius of curvature is 24 mm
in the coronal plane, and the average thickness is
19 mm [11]. The average articular surface diam-
eter has been reported as 43 mm [12]. The greater
and lesser tuberosities serve as attachment points
for the rotator cuff tendons (Fig. 1.5). The sub-
scapularis attaches to the lesser tuberosity. The
supraspinatus, infraspinatus, and teres minor
attach to the greater tuberosity. The bicipital
groove is found between the two tuberosities, and
can serve as a landmark during surgery. The ret-
roversion of the proximal humerus can be vari-
able anywhere from 10–50° and is usually quoted
Fig. 1.3 Posterior view of a left scapula as averaging 30° [13].
6 N.G. Garbis
Fig. 1.6 Left shoulder: acromial side of the A/C joint. The
entire capsule, detached from the clavicular side, is still
attached at the acromial side, making the acromioclavicular
ligaments visible (ACR acromion, articular side, AL a/c
anterior acromioclavicular ligament, IL a/c inferior acro-
mioclavicular ligament, PL a/c posterior acromioclavicular
ligament. SL a/c superior acromioclavicular ligament) [38]
Fig. 1.5 Posterior and anterior views of the proximal
humerus demonstrating the tuberosities and the bicipital
groove
Acromioclavicular Joint
Moving laterally, the acromioclavicular (AC)

Sternoclavicular Joint joint is the articulation between the lateral end of
the clavicle and the medial end of the acromion.
The sternoclavicular joint is a synovial joint at The articular ends of both the clavicle and the
the superior end of the sternum and the medial acromion are covered with fibrocartilage. In
aspect of the clavicle [14]. It has been described addition to the fibrocartilage, there is an articular
as both a ball and socket joint and a saddle joint disc that is meniscoid in nature and covers
[15]. In addition, the first costal cartilage is at mostly the superior portion of the joint [18]
the inferior aspect of the sternoclavicular joint. (Fig. 1.6). The angle of the joint can be quite
The sternoclavicular joint serves as the only variable, and should be considered if any surgi-
bony connection of the axial skeleton to the cal procedure is to be undertaken [19]. Most of
upper extremity. The ligamentous restraints of the stability in the anterior and posterior direc-
the joint come from thickenings of the capsule. tion is provided by the AC ligament. The coraco-
The primary restraint of the sternoclavicular clavicular (CC) ligaments are composed of the
joint is the posterior sternoclavicular ligament. conoid (posteromedial) and the trapezoid
There is an articular disc that attaches superi- (anterolateral) ligaments. These serve to main-
orly and inferiorly that lies between the medial tain the craniocaudal relationship between the
end of the clavicle and the sternum [16]. There clavicle and the coracoid and provide most of the
is also a costoclavicular ligament which con- vertical stability [20].
nects the medial end of the clavicle to the first
rib (Fig. 1.1). This helps restrict superior migra-
tion of the clavicle. There is approximately Glenohumeral Joint
30–35° of elevation and 35° of flexion and
extension [3]. Most of the motion at the sterno- The glenohumeral joint is the “ball in socket” or
clavicular articulation occurs in the first 90° of more appropriately “ball on golf tee” joint that
elevation [17]. allows a significant amount of mobility to position
1 Shoulder Anatomy 7
Fig. 1.8 Left cadaveric shoulder demonstrating labrum

Fig. 1.7 Left shoulder, frontal view (DEL deltoid, GLEN
and intraarticular ligaments [37] (Chapter 9, Apostolakos
glenoid, HH humeral head, SSP supraspinatus)
et al.)
(Digiacomo and Dr. Pau Golanò) [38]
the arm in space (Fig. 1.7). To account for this

mobility, there are several static and dynamic
restraints to range of motion. Unlike the hip, only
a small portion of the humeral articular surface is
in contact with the glenoid at any given point [21].
The glenoid labrum surrounds the bony glenoid
and is a ring of fibrocartilage that serves to deepen
articular surface and provide stability [22]. The
labrum also serves as an attachment site for the
glenohumeral ligaments, joint capsule, and long
head of the biceps tendon [23] (Fig. 1.8).
Any alteration in the structure and morphology
of the glenohumeral joint can lead to increased
instability. Changes in the articular version can lead
to increased instability. Additionally, capsulolabral
tears can allow for increased glenohumeral transla- Fig. 1.9 Arthroscopic image of the middle glenohumeral
ligament coming off at 90° angle to the subscapularis ten-
tion. Fractures or recurrent dislocations with bone don. Patient is in the beach chair position, image taken
loss can decrease the effective glenoid articular sur- from the posterior portal (Nickolas G. Garbis, MD)
face, which can lead to increased instability. The
fluid in the shoulder producing an adhesion-cohe- The inferior glenohumeral ligament is a ham-
sion effect can also stabilize the joint [24]. mock like structure at the inferior aspect of the
As mentioned previously, the capsule and shoulder. It has been described as being com-
labrum play a large part in the stability of the posed of three parts: the anterior band (AIGHL),
joint. There are several named thickenings of the the posterior band (PIGHL) and the axillary
joint capsule that serve as named ligamentous pouch (AxIGHL) [26]. When the arm is placed in
stabilizers of the glenohumeral joint [25] abduction the ligament tightens and further tight-
(Fig. 1.8). As static stabilizers, they come into ens in external rotation to maintain the humeral
play at the end range of motion in various direc- head centered in the glenoid. The middle gleno-
tions, as the structures are placed on stretch. humeral ligament (Fig. 1.9) limits external
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[346] Como, no me parece aquí correlativo de tal, leo así: «Yo, como vano e
incauto había jurado nunca más meterme, etc...»
[347] al camino por en el camino; este uso de al se conserva aún como
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[348] como perdidos: ciegamente como locos. (V. Canc. I, verso 12.)
[349]turo de turar: durar, permanecer. En los valles del Pirineo aragonés es
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[350] tamaño, tam magnus, quiere decir propiamente tan grande, pero aquí
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vivir en clima tan frío. Del uso de esta palabra en este verso han hablado
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pág. 680-681.
[351] «Este soneto es, sin comparación, el más dulce y suave de los de
Garcilaso.» (Azara.)
[352] «Acordábase el Cisne que sus plumas habían vestido más color de
fuego que de nieve... que su corazón había quemado muchas veces las alas
en torno de unas luces mentidas... y comenzó a llorar lo que antes había
cantado; porque derribando de su memoria las imágenes que habían
ocupado sus aras, deshojando esperanzas y prendas antiguas, decía
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52.)
[353]También Herrera en un soneto decía al Betis: «... destilado — Iré en tu
curso largo y extendido, — en llanto desatado — Seré en tus blancas manos
recogido.» (Anotaciones, pág. 129.)
[354] Dicen que fue Dafne una hermosísima hija del río Perseo, de Tesalia, y
que encendido Apolo en amor loco, la seguía, perdido por ella; y ya que la iba
alcanzando, suplicó Dafne a la Tierra, su madre, que la recogiese en sí,
librándola de aquel trance, y la tierra escuchó su voto y transformó a la
doncella en un bello laurel, al pie del cual tanto ha llorado Apolo su imposible
amor, que con sus lágrimas mantiene al laurel siempre verde y lozano.
(Ovidio, Metam., lib. I, fáb. X.)
[355] El símil de la madre y el hijo doliente contenido en estos primeros
versos, hállase también rimado por Boscán y Hurtado de Mendoza, y
procede, según el Brocense, nota 16, y Menéndez y Pelayo, Antología, XIII,
302, del gran poeta del amor, Ausías March: «Li’n pren aixi com dona ab son
infant, — Que si veri li demana plorant, — Ha tant poch seny que no l’sab
contradir.» (Cants d’Amor, XXVIII.)
[356] Recuerda en estos versos el prodigio del amoroso llanto de Orfeo, por
manera semejante a como se lee en las dos primeras liras de la Canción A la
Flor de Gnido.
[357] Hizo Garcilaso este soneto como epitafio a la sepultura de su hermano
D. Fernando, que murió de pestilencia en Nápoles, de edad de veinte años,
hallándose en el ejército del Emperador Carlos V contra los franceses.
[358] Ese fiero ruido que quiere imitar el estampido del rayo que Vulcano
labró en las fraguas del Etna para el padre Júpiter, es el ruido de la artillería,
«cruelísimo linaje de máquina militar que llamaron bombarda, del estruendo y
ardor, y nosotros lombarda... Pero no eran estas como las de ahora, sino más
cortas y más gruesas, que por ventura debían ser las piezas que hoy llaman
morteros.» (Herrera, págs. 149-150.)
[359] Parténope es la ciudad de Nápoles, como queda dicho en la Eleg. II, v.
38.
[360] «Por ventura fue este numeroso y bellísimo y afectuoso soneto escrito a
Julio César, poeta napolitano, de la nobilísima casa Caraciola de aquel
reino.» (Herrera, página 184.)
[361] Garcilaso, partiendo de Nápoles, parece ser que había ido
precisamente adonde vivía la dama de Julio, y Julio había quedado en
Nápoles, donde vivía la dama de Garcilaso; uno y otro, pues, podían
cambiarse nuevas, noticias, de sus damas respectivas. ¿Por qué ha de ser
ridículo de puro exquisito, este modo de explicarse? Azara es algo
descontentadizo: Garcilaso no escribió este soneto para nosotros, sino para
Julio, que estaría bien enterado de los pormenores de su asunto, y que, por
consiguiente, no había de tropezar en las dificultades de que Azara protesta.
[362]Una ausencia de la dama del poeta le inspiró las quejas del presente
soneto.
[363] En un ejemplar antiguo que manejó el Brocense, nota 24, leíase
largueza en vez de guerra, palabra que, a mi juicio, aclara más el
pensamiento del poeta, el cual, acongojado por la partida de su dama,
abrázase a su propia pena, deseando atajar así la largueza del camino, es
decir, deseando abreviar su vida.
[364] «Este soneto fue escrito a D. Pedro de Toledo, Marqués de Villafranca y
Virrey de Nápoles; aunque algunos piensan que a D. Alonso de Ávalos,
Marqués del Vasto, grande amigo de Garcilaso.» (Herrera, pág. 168.)
[365] «El argumento de este soneto es caso particular, y por eso difícil de
inteligencia. Parece que yendo a ver a su señora, que tenía descubiertos los
pechos, el poeta puso los ojos en ellos, alargándose en la consideración de la
belleza del alma, aunque el duro encuentro de la hermosura corporal impidió
su intento, y compelió a olvidar su primer pensamiento y parar en la belleza
exterior.» (Herrera, pág. 170.)
[366] La precedente explicación pareció a Herrera más acertada que las
demás conjeturas que se le ocurrieron, y en esto coincidió con el Brocense, el
cual decía de este primer terceto, que la dama, pesándole de que el poeta le
hubiese visto el pecho, «acudió con la mano a cubrillo y hiriose, con algún
alfiler de la beatilla, en él». (Nota 25) Tamayo, fol. 11, se muestra conforme
con esta interpretación más material que espiritual; sin embargo, Azara dice
que «las circunstancias con que lo visten Herrera y Sánchez son conjeturas
que no satisfacen».
[367] gonna: ropa larga de mujer, a manera de bata. El poeta, considerando
la picadura del alfiler como golpe de saeta de amor, se duele de que su
herida no hubiese pasado más allá de la gonna. Este verso «del Petrarca,
Canc. IV, Stanc. II, reprehenden, por ser introducido entre los castellanos;
más engáñanse, no considerando que debía de ser este soneto para alguna
señora de Italia, donde tan favorecido vivió Garcilaso, fuera de que no es
cosa vituperable cuando se toman estos versos de hombres insignes»...
(Tamayo, notas, fol. 11.)
[368] Dice la Pipota en Rinconete y Cortadillo: «Holgaos, hijos..., que vendrá
la vejez y lloraréis en ella los ratos que perdisteis en la mocedad, como yo los
lloro»; que no es otra cosa sino lo que dijo Ausonio en su famoso epigrama:
«Collige, virgo, rosas...», mil veces repetido y parafraseado por los poetas
españoles y extranjeros (V. ejemplos en Herrera, Anotaciones, págs. 175,
186, y F. Rodríguez Marín, Barahona, págs. 295-297 y 628-630), y asimismo,
lo que una vieja de antigua edad aconsejaba a la bella Melisenda, encendida
en amores del Conde Ayuelos: «Mientras sois moza, mi hija, — placer vos
querades dar — que si esperáis a vejez — no vos querrá un rapaz.» (R.
Menéndez Pidal, El Romancero Español, The Hispanic Society of America,
1910, pág. 26.)
[369] «Este soneto fue escrito a la Marquesa de la Padula, D.ª María de
Cardona, hija del Marqués D. Juan de Cardona... Fue su esposo D. Artal de
Cardona, Conde de Colisano... Después casó en el año de 1538 con D.
Francico de Este, hermano del Duque de Ferrara. Por ella escribió Mario de
Leo el Amor preso, y a ella dedicó el Gesualdo sus Comentos en Petrarca.
Fue muy discreta y valerosa, inclinada al conocimiento de la historia y poesía,
y aunque no muy hermosa, tuvo mucha gracia y donaire.» (Herrera, pág.
187.)
[370] Se ha hecho clásico este elogio de llamar décima Musa a una dama
docta, como cuarta Gracia a una dama bella, siendo nueve las Musas, las
moradoras del Parnaso, y las Gracias, tres; D. Adolfo de Castro llama a doña
Cristobalina Fernández de Alarcón décima musa antequerana (Auts. Esps.
Poetas Líricos de los siglos xvi y xvii, Madrid, 1854, tomo I, pág. 31), y el Sr.
Rodríguez Marín (Luis Barahona de Soto, Madrid, 1903, pág. 425), a
propósito de D.ª Rosalía de Castro, dice también «la dulce Rosalía, décima
musa del Parnaso de España, y no primera, sino única, del gallego».
[371]Luis Tansillo (¿1510?-1568), poeta italiano, autor del malicioso poema Il
Vendemmiatore, que la Inquisición condenó, y de Le Lagrime di San Pietro.
Estuvo con Garcilaso en la expedición a Túnez. — Antonio Sebastián
Minturno, obispo y literato italiano ( † 1574), que escribió varias poesías y
libros de erudición. — Bernardo Tasso, (1493-1569), poeta italiano también,
Secretario del Príncipe de Salerno, cantor de la bella Ginebra Malatesta,
amante de Tulia de Aragón y padre del famosísimo Cisne de Sorrento, que
escribió la Jerusalén conquistada y la Aminta. Bernardo Tasso fue autor del
poema Amadigi (Amadís de Gaula).
[372] Helicona por Helicón. Monte de Grecia consagrado por los poetas como
el Pindo y el Parnaso; en él tenían su morada Apolo y las Musas.
[373] Habla el poeta junto a la sepultura de su dama.
[374]Este soneto, por su honda melancolía y por la llaneza de su forma, me
parece uno de los mejores de Garcilaso. Es un lamento lleno de amargura.
Los que le han censurado cuando sutiliza y alambica a la manera italiana, no
debieran haber callado su elogio en este lugar.
[375] El poeta, experimentado en amarguras, había jurado nunca más amar,
pero una sirena napolitana cautivó su espíritu, soneto VII; dio cuenta a
Boscán del principio de esta aventura en el soneto XXVIII, guardando,
respecto a quien fuese la dama, absoluta reserva; esto pudo ocurrir a fines de
1532; el poeta no era ya un mancebo, pero se enamoró con loco
encendimiento, y rindiose apasionadamente a la sirena misteriosa, soneto V;
un feliz descuido del tocado, soneto XXII, le arriesgó a un consejo malicioso,
soneto XXIII, y, al mismo tiempo, lamentaba rigores, cuidados,
arrepentimientos y sospechas, sonetos XV, XX, XXVII, XXX y XXXI. Llegó la
empresa de África: el poeta, desde Túnez, duélese de su ausencia, soneto
XXXV; y desde Sicilia, a su regreso, confía a Boscán sus inquietudes,
temeroso de olvidos y mudanzas, Elegía II. Volvió el poeta a Nápoles, hacia
septiembre de 1535; su dama no le había sido infiel, pero había muerto, o
acaso murió poco después de su llegada; en los sonetos XXV y XXVI hay un
hondo dolor, un dolor verdadero; un año después murió el poeta. Tal pudo
ser, en fin, esta historia sencilla y sentimental. Una duda: estos dos últimos
sonetos pueden ser también a la muerte de D.ª Isabel Freyre. (V. Eg. I., v. 2,
nota.)
[376] «Niega Morel-Fatio (L’Espagne au xvie et au xviie siècle, pág. 602) que
este soneto, imitado de Ausías March, pueda ser de Garcilaso, porque este
no se hubiera atrevido a truncar el endecasílabo, y le atribuye a Boscán o D.
Diego de Mendoza. Pero es cierto que Garcilaso, en la Canc. II, usa con
insistencia los versos agudos (véase la nota a la Canc. II, v. 68), y nada tiene
de particular que los emplease imitando unos versos de Ausías, puesto que el
original catalán los tiene también. Hay de este soneto una refundición en que
los agudos se han convertido en graves (publicada por Knapp, por Morel y
por Walberg, notas a Juan de la Cueva, pág. 91), según copias distintas:
Amor, amor, me ha un hábito vestido. Esta refundición lleva en los
manuscritos el nombre de Mendoza. Hay, finalmente, otra refundición,
también sin agudos, de que se valió el Brocense en su edición de Garcilaso.
D. Diego de Mendoza imitó el mismo pasaje de Ausías en una canción.» (M.
Menéndez y Pelayo, Antología, XIII, pág. 221, nota.)
[377] salvatiquez, en italiano selvatichezza. La e de la primera sílaba de
selvatiquez se ha transformado en a, por asimilación de la a siguiente, por
influencia de la forma vulgar salvaje (silvaticu), o por ambas causas; casos
análogos: balanza (bilance), zarcillo (circellu), ant. cercillo, etc. (V. R.
Menéndez Pidal, Gram. Hist., Madrid, 1905, § 18-3.) También otro cultismo:
parálisis, dejose influir por la forma vulgar perlesía, dando origen a paralisía.
(Bulletin de Dialectologie romane, Bruxelles, 1909, pág. 126.)
[378] Leandro, para ver a su amante Hero, atravesaba de noche, a nado, el
Helesponto. Hero le orientaba desde su torre con la luz de una antorcha. La
posibilidad del viaje de Leandro fue demostrada experimentalmente por Lord
Byron, atravesando a nado aquel estrecho, entre Sestos y Abidos, en 31 de
mayo de 1810, según él mismo refiere en una nota del canto 2.º de Don Juan.
Una noche de tempestad apagose la luz; Leandro, perdido entre bravas olas,
murió ahogado, y Hero murió también al descubrir desde la orilla su cadáver.
De la historia de este bello asunto en nuestra literatura ha hecho un magnífico
estudio el Sr. Menéndez y Pelayo en su Antología, tomo XIII, págs. 334-378.
[379] esecutá por ejecutad. (V. nota al v. 253 de la Eg. II.) La pérdida de la d
final en la pronunciación de los imperativos vení, poné, mirá, etc., nació, sin
duda, en el lenguaje familiar; este valor tiene el testimonio de Santa Teresa
(Las Moradas, ed. Clásicos Castellanos, Madrid, 1910, pág. 43, nota 16),
aparte de la tradición de dicho fenómeno conservada en la Argentina: cantá,
hacé, y en la lengua literaria ante el pronombre os: andaos, salíos (excepto
idos); pero los clásicos, desde Garcilaso, adoptaron también aquella
pronunciación, y pusiéronla en moda: «Andá, señor, que estáis muy mal
criado.» (V. Bello-Cuervo, Gramática, París, 1907, § 614; R. Menéndez Pidal,
Gram. Hist., § 107-2.)
[380] contrastado: resistido.
[381] poner por deponer, rendir las armas.
[382]despojos: las armas del vencido y demás restos de la derrota de que se
rodeaban los victoriosos en sus carros triunfales. (V. Canc. V, v. 17.)
[383] Endecasílabos de muiñeira, propuestos, como endecasílabos malos,
por no tener los acentos en su sitio, para ingresar en la sala segunda del
Hospital de los versos incurables, fundado por D. Eduardo Benot en su
Prosodia castellana y versificación, tomo III, págs. 154-249:
—Oh, crudo nieto, que das vida al padre—
—Ora clavando del ciervo ligero. —Eg. II, v. 194.
—Cómo pudiste tan presto olvidarte. —Eg. II, v. 578.
—Hace tremer con terrible sonido. —Hurtado de Mendoza.
—¡Qué! ¿no te acuerdas de cuando cantando? —Barahona.
—Se la mia vita dall’ aspro tormento. —Petrarca.
—Gran Cardinal di la Chiesa di Roma. —Ariosto.
(V. F. Rodríguez Marín, Barahona, pág. 425.)
[384]Supónese esta genealogía: El espíritu engendra el amor, y del amor, en
maridaje con la envidia, nacen los celos; estos, que son el monstruo parido
por la envidia, son el nieto cruel que encendiendo el amor matan el alma —
dan vida al padre y matan al abuelo.
[385] «Hermosísima alegoría por todo el terceto, y no sé si se hallará en la
lengua latina otra más ilustre y bien tratada que esta.» (Herrera, Anotaciones,
pág. 209.)
[386] A Mario Galeota. Soneto núm. XXXV en las ediciones de Azara y
Castro. Expedición a Túnez contra Barbarroja. El 14 de julio de 1535, el
ejército del Emperador se apoderó del fuerte de la Goleta, y estuvo en aquella
empresa Garcilaso con su hermano D. Pedro Laso, el Marqués de Lombay,
D. Diego Hurtado de Mendoza y otros muchos caballeros ilustres. Doce
guerreros, Garcilaso entre ellos, se atrevieron a acometer ochenta caballos
númidas que les provocaban; fue el aprieto grande; nuestro poeta fue
socorrido por Federico Carraffa, napolitano, y por el César en persona, que
sabiendo el peligro en que se encontraba le ayudó con sus hombres y peleó a
su lado. Garcilaso salió herido de dos lanzadas, en la mano diestra y en la
cara; esta le interesó la lengua, dejándole cierto defecto de pronunciación que
le agraciaba. (Cienfuegos, Vida del Grande San Francisco de Borja, pág. 50;
Navarrete, págs. 62, 65 y 66.)
[387] Alude a la leyenda de la famosa espada que Dionisio I, tirano de
Siracusa, hizo colgar, suspendiéndola de un cabello, sobre la cabeza de
Damocles, en tanto que le rodeaba de todo el regalo y la suntuosidad de un
rey, para dar a entender a aquel cortesano cuán poco envidiables eran las
grandezas que tanto le elogiaba, teniendo que gozarlas bajo la constante
amenaza de un peligro mortal: el odio, la envidia, la ambición.
[388] Como esto es lo que dijo D. Diego Hurtado de Mendoza en su carta IX,
tercetos 33-36, dirigida a don Diego Laso (Auts. Esps. Poetas líricos de los
siglos xvi y xvii, Madrid, 1854, tomo I, pág. 65):
«Dulce ver es de tierra un bravo viento...

No porque el mal ajeno te contente,
Mas porque, en la verdad, es dulce cosa
Carecer del dolor que el otro siente...»
Garcilaso y Mendoza, según Herrera, imitaron aquí a Lucrecio.

(Anotaciones, pág. 211.)
[389] A Boscán, desde la Goleta. Soneto núm. XXXIII, en Azara y Castro. Por
lo que Garcilaso dice en estos últimos versos de este soneto, se ha supuesto
que debió tener alguna aventura galante en la Goleta, durante la curación de
sus heridas (Cienfuegos, o. c., lib. II, pág. 50; Navarrete, pág. 66, nota 1); me
parece que no hay suficiente fundamento para esta conjetura; el 14 de julio,
con la toma de la Goleta, o acaso después, en alguna escaramuza, fue herido
Garcilaso, el 20 se sometió Túnez, y el 12 de agosto regresaron las tropas a
España; ciertamente, en menos de un mes que Garcilaso estuvo en la
Goleta, y con heridas que le tuvieron a los umbrales de la muerte (Navarrete,
pág. 65), ¿qué aventuras galantes había de tener?... más lógico es relacionar
estas quejas de su alma temerosa y estas incertidumbres de sus esperanzas,
con los temores y las incertidumbres de que pocos días después hablaba a
Boscán en la Eleg. II, por la suerte que en su ausencia hubiera podido seguir
el nido que su corazón había dejado en Nápoles.
[390] Hasta aquí llegan los sonetos en Herrera; los seis últimos, desde el
XXX inclusive, los admitió como auténticos por opinión común y por
afirmación de D. Antonio Puertocarrero, yerno de Garcilaso; pero desechó los
tres siguientes por no parecerle tan segura su autenticidad (Anotaciones, pág.
206); yo pongo también estos siguiendo una costumbre establecida; conservo
estrictamente el texto del Brocense, Opera Omnia, Genevae, 1766, tomo IV.
[391] De este soneto, como del XXXII y XXXVIII, decía el Brocense «que se
tienen por de Garcilaso, de un libro de mano».
[392] Tamayo admite este soneto como auténtico; el Brocense lo considera
dudoso; Herrera y Azara lo rechazan, y Castro lo tiene por indigno de
Garcilaso. Verdaderamente, con tan desdichado juego de sentir, siento,
sienta, sentillo y sello, su autor acertó a decir poco de provecho; tal vez no es
sino un pobre soneto advenedizo, que debe su fortuna al desconocido editor
de aquel libro de mano en que lo encontró el Brocense, figurando entre las
demás composiciones de Garcilaso como hijo de la misma mano.
[393] Estas pocas composiciones al estilo antiguo de Castilla, acaso no
fueron las únicas que escribió Garcilaso, pero la ruina que alcanzó
seguramente a todas las poesías de nuestro poeta, por causa de su
orfandad, debió señalarse en las de este género, como más humildes y
menos estimadas. Herrera no las acogió en su edición. Los versos cortos,
ante la magnificencia del endecasílabo italiano, vinieron a creerse incapaces
de conceptos graves, y por esto, y por ser vicio común dar más estima a las
cosas extrañas que a las nuestras, cayeron en menosprecio. (Tamayo, fols.
80-82.) Según Castro, esta primera Canción lleva en un manuscrito de Iriarte
el siguiente epígrafe: A doña Isabel Freyra, porque se casó con un hombre
fuera de su condición.
[394] En otras ediciones lleva este epígrafe: A una partida.
[395] Epígrafe: Traduciendo cuatro versos de Ovidio.
[396] «A una señora que andando él y otro paseando, les echó una red
empezada y un uso comenzado a hilar en él, y dijo que aquello había
trabajado todo el día.» En el citado manuscrito de Iriarte, según Castro, decía:
A D.ª Mencía de la Cerda que le dio una red y díjole que aquello había hilado
aquel día.
[397] «Glosa de Garci-Lasso sobre este villancico», dice el Brocense; el
villancico solo lo forman los tres primeros versos, y dice Castro que, según se
ve en las obras de Boscán, esta copla fue escrita a D. Luis de la Cueva
porque bailó en palacio con una dama que llamaban la Pájara. Boscán, el
Duque de Alba y otros muchos caballeros escribieron a propósito del mismo
asunto.
[398] «En un códice de poesías varias que perteneció al célebre anticuario
aragonés D. Vicencio Juan de Lastanosa, y más tarde a los Iriartes, se leen
estas redondillas: A Boscán, porque estando en Alemaña danzó en unas
bodas.» Las publicó Gayangos, notas a Ticknor, tomo II, pág. 488. El Sr.
Menéndez y Pelayo, Antología, XIII, pág. 479, supone que Boscán debió ir a
Alemania acompañando al Duque de Alba, como Garcilaso, cuando el
socorro de Viena, 1532, aunque el poeta no le menciona en la descripción
que de aquel viaje dejó en la Eg. II.
[399] Esta carta escribió Garcilaso de la Vega en 1533, hallándose en
Barcelona como emisario del Virrey de Nápoles; sirve de prólogo a la
traducción de El Cortesano hecha por Boscán, y es la única muestra que la
áurea pluma de nuestro poeta dejó de la excelencia de su prosa. D.ª
Jerónima Palova de Almogávar, parienta, acaso de Boscán, a juzgar por el
segundo apellido, es la misma a quien este dedicó su libro. Sigo el texto dado
por D. Tomás Tamayo de Vargas en su edición de Garcilaso, Madrid, 1622. El
Brocense, Herrera, Azara y Castro no publicaron esta carta.
[400] «Andando yo en estas dudas, Vuestra Merced ha sido la que me ha
hecho determinar, mandándome que le tradujese; y así todos los
inconvenientes han cesado, y solo he tenido ojo a serviros.» (Boscán, Carta-
dedicatoria a D.ª Jerónima Palova.)
[401] «Mas como estas cosas me movían a hacello, así otras muchas me
detenían que no lo hiciese, y la más principal era una opinión que siempre
tuve de parecerme vanidad baja y de hombres de pocas letras andar
romanzando libros; que aun para hacerse bien vale poco, cuanto más
haciéndose tan mal que ya no hay cosa más lejos de lo que se traduce que lo
que es traducido... viendo yo esto, y acordándome del mal que he dicho
muchas veces de estos romancistas (aunque traducir este libro no es
propiamente romanzalle, sino mudalle de una lengua vulgar en otra quizá tan
buena), no se me levantaban los brazos a esta traducción.» (Boscán, ibid.)
[402] Y aun antes de que viniese a manos de Boscán, puesto que Garcilaso
fue quien lo envió a su amigo desde Italia: «No ha muchos días que me envió
Garcilaso de la Vega, como Vuestra Merced sabe, este libro llamado El
Cortesano, compuesto en lengua italiana por el Conde Baltasar Castellón.»
(Boscán, ibid.)
[403] El famoso autor de Il Cortegiano, Baltasar Castiglione, nació en tierra de
Mantua, el 6 de diciembre de 1478, y murió en Toledo el 2 de febrero de
1529, siendo Nuncio en España del Papa Clemente VII, en cuyo tiempo las
tropas imperiales saquearon a Roma. El Conde Castiglione «fue hombre de
armas y hombre de corte, aventajado en todos los ejercicios y deportes
caballerescos, maestro en el arte de la conversación y en todo primor de
urbana galantería; profesor sutil de aquella filosofía de amor que la escuela
platónica de Florencia había renovado doctamente; curioso especulador de la
belleza en los cuerpos, en las almas y en las puras ideas; conocedor fino en
las artes del diseño; amigo y consejero de Rafael, en quien parece haber
inoculado su propio idealismo estético; pensador político y ameno moralista;
poeta lírico y dramático y organizador de fiestas áulicas: todas estas cosas
era Castiglione, sin sombra de pedantismo, con aquella cultura íntegra y
multiforme, con aquella serena visión del mundo que renovaba los prodigios
de la antigüedad en algunos espíritus selectos del siglo xvi». (M. Menéndez y
Pelayo, Antología, XIII, págs. 80-81.) Primera edición de su obra: Il Libro del
Cortegiano | del Conte Baldesar | Castiglione (Escudo del impresor con el
áncora aldina.) Colofón: In Venetia, nelle case d’Aldo Romano, et d’Andrea
d’Asola | suo Suocero nell’ anno MDXXVIII | del mese d’aprile. La más sabia
edición y comentario: Il Cortegiano del Conte Baldesar Castiglione, annotato
e illustrato da Vittorio Cian. Firenze, Sansoni, 1894.
[404] Libros que matan hombres; ¿aludirá a los de Caballerías? Sería de
notar tan temprana protesta.
[405] «Yo no terné fin en la traducción deste libro a ser tan estrecho que me
apriete a sacalle palabra por palabra; antes, si alguna cosa en él se ofreciere,
que en su lengua parezca bien y en la nuestra mal, no dejaré de mudarla o de
callarla.» (Boscán, ibid.)
[406]«El sujeto del libro es tal, y su proceso tan bueno, que quien le leyere
será muy delicado si entre tantas y tan buenas cosas no perdonare algunas
pequeñas, compensando las unas con las otras.» (Boscán, ibid.)
[407] Publicó Boscán su traducción en 1534: Los cuatro libros del Cortesano,
compuestos en italiano por el Conde Baltasar | Castellón, y agora
nuevamente traducidos en len | gua castellana por Boscán. (Escudo de las
armas reales.) Con privilegio imperial por diez años. Colofón: Aquí se acaban
los cuatro libros del Cortesa | no, compuestos en italiano por el Conde
Baltasar Castellon, y traducidos en lengua castellana por Boscán, imprimidos
en | la muy noble ciudad de Barcelona por Pedro Mon | pezat, imprimidor. A
dos del presente mes de abril | Mil y quinientos treinta y cuatro. Fol. gót., 113
hojas.
[408] Don Eustaquio Fernández de Navarrete, hablando de la traducción de
El Cortesano dice: «Al ver la gran ventaja que su elegante y castiza prosa
lleva, no solo a los duros y penosos versos del autor (Boscán), sino aun a la
de los prólogos que acompañan sus poesías, hemos sospechado que en esta
perfección debió tener parte la mano de Garcilaso. Este, por empeño de
Boscán, estuvo presente a la última línea, y aunque por modestia nos diga
que asistió más como hombre acogido a razón que como ayudador de
ninguna enmienda, no cabe duda de que sus consejos y advertencias serían
de grande utilidad al traductor. Nos dice, además, que él tomó a su cargo la
copia que se remitió a D.ª Jerónima —esto parece decir en las dos últimas
líneas—; y en ella su gusto y conocimiento de la lengua, es posible
corrigiesen todo aquello que ofendiese a sus delicados oídos, dando así a
esta obra un sabor de elegancia de que carecen las obras de Boscán.» Vida
de Garcilaso, Col. de documentos inéditos para la Historia de España, tomo
XVI, pág. 165. Todo esto es mera conjetura, y es, a mi juicio, querer deducir
demasiado de las palabras de Garcilaso; para menguar de tal modo a Boscán
la gloria de su trabajo se necesitan pruebas más seguras; por otra parte, la
carta de Boscán, muestra cierta de su prosa, a D.ª Jerónima Palova, está
evidentemente a la altura de la de Garcilaso y no desdice del estilo de lo
demás del libro; por estas razones, acaso, el Sr. Menéndez y Pelayo en su
libro Juan Boscán no hizo mención de las sospechas de Navarrete.
[409] «De antiguo viene la costumbre de los prólogos ajustados por mano
amiga al talle de la obra, pero pocos habrá tan galanos y discretos como este
y tan finamente justos. El fallo de Garcilaso quedó como inapelable.» (M.
Menéndez y Pelayo, Antología, XIII, pág. 114.)
[410] Don Álvaro de Bazán, Capitán General de las Galeras de España,
aportó en Génova el 19 de mayo de 1536 con 3000 soldados españoles,
reclamados por el Emperador para la guerra que se preparaba contra el rey
francés. Garcilaso fue nombrado Maestre de Campo de estos soldados, y
hallándose en Génova para recibirles, escribió al Emperador la presente carta
dándole cuenta de su gestión. El Sr. Navarrete puso al frente de su Vida de
Garcilaso un facsímil de esta carta que se conserva autógrafa. Dicho facsímil
transcribo conservando todos sus detalles para que pueda tenerse más fiel
idea del original.
[411] S. C. C. M. Sacra Cesárea Católica Majestad.
[412] El Príncipe a quien Garcilaso se refiere es el famoso Capitán Andrea
Doria, de cuya autoridad dependía él por orden del Emperador.
[413]Era embajador español en Génova el caballero don Gómez Suárez de
Figueroa.
[414] Nuestro Señor la Sacra persona de Vuestra Majestad, etc.
[415] Srios, señoríos.
[416] En el sobre dice: A la S. C. C. M. del Emperador Rey nuestro Señor.
[417] Sigo el texto dado por Tamayo, el cual, a propósito de este epigrama de
Garcilaso, dice: «De sus versos latinos, celebrados por el Bembo, Tansillo,
Jovio y Boscán nos quedó por muestra un elegantísimo epigrama al fin del
Caballero Determinado de D. Fernando de Acuña, que es tal que no se puede
mejorar en invención, elocución y gallardía.»
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The Shoulder 1st Edition Gazi Huri Download PDF

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Shoulder Arthroplasty: The Shoulder Club Guide Gazi Huri

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More information about this series at http://www.springer.com/series/13489

ISSN 2520-1115 ISSN 2520-1123 (electronic)

Library of Congress Control Number: 2017946755

© Springer International Publishing AG 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

To my teachers that dedicated their life to medical education

It is an honor and a pleasure for me to write the introduction to the inaugural

Baltimore, MD, USA Edward G. McFarland

Ankara, Turkey Mahmut Nedim Doral

The medical field is continuously changing and growing—aiming to perfect

Part I Basic Science

1 Shoulder Anatomy �������������������������������������������������������������������������� 3

Part II Clinical Evaluation

Part III Investigations

7 Three-Dimensional Visualization in Clinical

Part IV Shoulder Trauma

9 Proximal Humerus Fractures ������������������������������������������������������ 101

Part V Specific Shoulder Disorders

13 Inflammatory Arthropathy of the Shoulder�������������������������������� 151

Part VI Non-operative Management of Shoulder Disorders

17 Splints and Orthoses���������������������������������������������������������������������� 205

Part VII Operative Management of Shoulder Disorders

20 Arthroscopic Positioning: Beach Chair Versus Lateral ������������ 265

22 Reverse Shoulder Arthroplasty���������������������������������������������������� 293

Gazi Huri, M.D. is an Associate Professor

Antoine Adam, M.D. Orthopedic, Traumatology, and Hand Surgery Unit,

Kyubo Choi, M.D. Division of Shoulder Surgery, Department of Orthopaedic

Saygin Kamaci, M.D. Department of Orthopaedic Surgery, University of

Ashnaa Rao, M.D. Johns Hopkins School of Medicine, Baltimore,

The shoulder is a complex joint that is essential Sternum

© Springer International Publishing AG 2017 3

Fig. 1.1 Diagram of

the body. It also serves as protection for underly-

The scapula is a flat triangular bone with multiple

Moving laterally, the acromioclavicular (AC)

Fig. 1.8 Left cadaveric shoulder demonstrating labrum

the arm in space (Fig. 1.7). To account for this

«Dulce ver es de tierra un bravo viento...

Garcilaso y Mendoza, según Herrera, imitaron aquí a Lucrecio.

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Baltimore, MD, USA Edward G. McFarland

Ankara, Turkey Mahmut Nedim Doral

1 Shoulder Anatomy �� 3

7 Three-Dimensional Visualization in Clinical

9 Proximal Humerus Fractures �� 101

13 Inflammatory Arthropathy of the Shoulder�� 151

17 Splints and Orthoses�� 205

20 Arthroscopic Positioning: Beach Chair Versus Lateral �� 265

22 Reverse Shoulder Arthroplasty�� 293

The shoulder is a complex joint that is essential Sternum