Shoulder Problems

Shoulder Problems Fractures Instability Impingement Miscellaneous MUN Ortho Anatomy Bones  Joints / Ligaments  Muscles  Neurovascular  MUN Ortho Anatomy MUN Ortho Anatomy Supraspinatus Anterior Posterior MUN Ortho Anatomy MUN Ortho Neurovascular Anatomy MUN Ortho Anatomy:Joints Acromioclavicular  Glenohumeral  Sternoclavicular  “Scapulothoracic”  MUN Ortho Shoulder problems : History Onset,duration,location  ??trauma  radiation of pain  ?C-spine problems  instability,”dead arm”  repetitive use  MUN Ortho Physical Examination deformity eg AC sep’n  ROM passive & active  Impingement tests  Instability tests  neurovascular exam  MUN Ortho Shoulder Problems Acute Pain ? Trauma Fractures Neer Classification Dislocations AMBRI & TUBS Inflammation Calcific Septic MUN Ortho Trauma !! MUN Ortho Fractures Clavicle  Proximal Humerus  Scapula / Glenoid  MUN Ortho Clavicle Fractures Common  Most heal uneventfully  Figure of 8 x 6 weeks  Beware of high energy ie MVA  Assoc ‘d soft tissue  MUN Ortho CLAVICLE FRACTURE MUN Ortho Clavicle Fractures : Figure 8 bandage MUN Ortho Proximal Humerus Fractures Neer- 4 parts  Vascularity of articular fragment  Displacement > 1 cm  Angulation > 45 degrees  Xray vs. CT scan  Interobserver variability  MUN Ortho Fractures : The Four Parts MUN Ortho Fractures MUN Ortho Proximal Humerus Fractures Treatment Undisplaced & 2-part : Sling  3- part : ORIF  4- part : Prosthesis  MUN Ortho 4 PART FRACTURE MUN Ortho NEER PROSTHESIS MUN Ortho 3 PART FRACTURE MUN Ortho ORIF 3 PART MUN Ortho Fractures :Scapula / Glenoid Rare  Most treated conservatively  Intraarticular displacement may need ORIF  MUN Ortho Shoulder Instability Traumatic vs. Habitual  Unidirectional vs. Multidirectional  Unilateral vs. Bilateral  MUN Ortho Anterior Shoulder Instabliity Hx of significant trauma  Very Painful  Most common  Nerve injury esp. axillary  Xray : Hill-Sachs defect  MUN Ortho The “Y” lateral Xray MUN Ortho The “Y” lateral Xray MUN Ortho Bankart and Hill-Sach’s lesions MUN Ortho Anterior Shoulder Instability Needs urgent reduction  Muscle relaxation,traction,patience  Post reduction exam(neuro) & Xray  Gilchrist sling  Tell patient recurrence risk  recurrent dislocation requires surgery  MUN Ortho Anterior dislocation ;reduction MUN Ortho Anterior Shoulder Instability Surgery involves repair of torn anterior structures  Bankart lesion  High success rate with several different procedures  MUN Ortho Anterior Shoulder Instability Traumatic  Unidirectional  Bankart  Surgery  MUN Ortho Multidirectional Instability anterior,posterior,inferior  voluntary  atraumatic  ligament laxity  some are assoc’d with psychological problems  MUN Ortho Multidirectional Instability Atraumatic  Multidirectional  Bilateral  Rehabilitation  Inferior Capsular Shift (RARELY)  MUN Ortho Acromioclavicular Separations Hockey , bikes  Coracoclavicular & Acromioclavicular ligaments  Grade 1-6  Most treated conservatively  Late excision of outer end of clavicle  MUN Ortho The Clavicular Ligaments MUN Ortho Acromioclavicular Ligaments MUN Ortho MUN Ortho Inflammation:Calcific Tendonitis Acute occ. severe pain  Mimics infection  Marked decrease ROM  Xray : Fluffy density near greater tuberosity  NSAIDS  MUN Ortho Calcific Tendonitis MUN Ortho Inflammation Septic  Gout  RA flare-up  MUN Ortho Shoulder Pain : Chronic Chronic Shoulder Pain Impingement Syndromes Rotator cuff tendonitis cuff tears AC arthritis Osteoarthritis Rheumatoid Arthritis AVN Frozen Shoulder Benign tumors Malignant tumors primary secondary MUN Ortho Impingement Syndromes Subacromial bursitis  Rotator cuff tendonitis  Bicipital tendonitis  AC arthritis  Rotator cuff tear  MUN Ortho Impnigement : Anatomy MUN Ortho Acromion Morphology MUN Ortho Impingement : Supraspinatus MUN Ortho Impingement :Hx & Px Repetitive overhead use of arm  Swimmers,pitchers  painful arc  impingement signs  decreased ROM active vs. passive  pain with resisted motion  MUN Ortho Impingement : treatment Avoidance of offending activity  Physiotherapy  NSAIDS  Corticosteroid injection  Surgery : Subacromial decompression  MUN Ortho Impingement : Imaging Xrays : often normal  Xrays : shape of acromion  Arthrogram  MRI  MSK Ultrasound  MUN Ortho MRI ROTATOR CUFF MUN Ortho Impingement :Surgery Arthroscopic vs open decompression  Cuff repair  Excision outer end of clavicle  MUN Ortho Impingement : Acromioplasty MUN Ortho Rotator Cuff Repair MUN Ortho Frozen Shoulder primary vs. secondary  prolonged stiffness  usually self-limited  lasts up to 2 years  physio/injection manipulation  benign neglect  MUN Ortho RA Shoulder usually obvious diagnosis  joint and tendon damage  steroid injections  synovectomy  Total shoulder arthroplasty  MUN Ortho OA & AVN uncommon  end stage can be treated by arthroplasty  AVN risk factors  MUN Ortho OA SHOULDER MUN Ortho Tumors primary relatively rare  always think of metastatic disease in patients > 50  night pain  Xray : bone destruction  MUN Ortho Tumors MUN Ortho