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					            Shoulder Problems

                 Fractures
                 Instability
               Impingement
               Miscellaneous
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       Anatomy
             Bones
             Joints / Ligaments
             Muscles
             Neurovascular




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       Anatomy




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       Anatomy
             Supraspinatus




            Anterior
                             Posterior




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       Anatomy




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       Neurovascular Anatomy




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       Anatomy:Joints
             Acromioclavicular
             Glenohumeral
             Sternoclavicular
             “Scapulothoracic”




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       Shoulder problems : History
             Onset,duration,location
             ??trauma
             radiation of pain
             ?C-spine problems
             instability,”dead arm”
             repetitive use



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       Physical Examination
             deformity eg AC sep’n
             ROM passive & active
             Impingement tests
             Instability tests
             neurovascular exam




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       Shoulder Problems


                                    Acute Pain
                                    ? Trauma


               Fractures           Dislocations   Inflammation
            Neer Classification   AMBRI & TUBS        Calcific
                                                      Septic




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       Trauma !!




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       Fractures
             Clavicle
             Proximal Humerus
             Scapula / Glenoid




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       Clavicle Fractures
             Common
             Most heal uneventfully
             Figure of 8 x 6 weeks
             Beware of high energy ie MVA
             Assoc ‘d soft tissue




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       CLAVICLE FRACTURE




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            Clavicle Fractures :
               Figure 8 bandage




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       Proximal Humerus Fractures
             Neer- 4 parts
             Vascularity of articular fragment
             Displacement > 1 cm
             Angulation > 45 degrees
             Xray vs. CT scan
             Interobserver variability



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            Fractures : The Four Parts




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       Fractures




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       Proximal Humerus Fractures
       Treatment
             Undisplaced & 2-part : Sling
             3- part : ORIF
             4- part : Prosthesis




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            4 PART FRACTURE




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       NEER PROSTHESIS




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       3 PART FRACTURE




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       ORIF 3 PART




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       Fractures :Scapula / Glenoid
             Rare
             Most treated conservatively
             Intraarticular displacement may need
              ORIF




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       Shoulder Instability
             Traumatic vs. Habitual
             Unidirectional vs. Multidirectional
             Unilateral vs. Bilateral




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       Anterior Shoulder Instabliity
             Hx of significant trauma
             Very Painful
             Most common
             Nerve injury esp. axillary
             Xray : Hill-Sachs defect




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       The “Y” lateral Xray




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       The “Y” lateral Xray




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       Bankart and Hill-Sach’s lesions




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       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



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       Anterior dislocation ;reduction




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       Anterior Shoulder Instability
             Surgery involves repair of torn anterior
              structures
             Bankart lesion
             High success rate with several different
              procedures




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       Anterior Shoulder Instability
             Traumatic
             Unidirectional
             Bankart
             Surgery




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       Multidirectional Instability
             anterior,posterior,inferior
             voluntary
             atraumatic
             ligament laxity
             some are assoc’d with psychological
              problems


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       Multidirectional Instability
             Atraumatic
             Multidirectional
             Bilateral
             Rehabilitation
             Inferior Capsular Shift (RARELY)




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       Acromioclavicular Separations
             Hockey , bikes
             Coracoclavicular & Acromioclavicular
              ligaments
             Grade 1-6
             Most treated conservatively
             Late excision of outer end of clavicle




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       The Clavicular Ligaments




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       Acromioclavicular Ligaments




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       Inflammation:Calcific Tendonitis
             Acute occ. severe pain
             Mimics infection
             Marked decrease ROM
             Xray : Fluffy density near greater
              tuberosity
             NSAIDS




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       Calcific Tendonitis




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       Inflammation
             Septic
             Gout
             RA flare-up




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       Shoulder Pain : Chronic


                                  Chronic Shoulder Pain


       Impingement Syndromes         Osteoarthritis        Benign tumors
        Rotator cuff tendonitis   Rheumatoid Arthritis    Malignant tumors
              cuff tears                 AVN                   primary
             AC arthritis          Frozen Shoulder           secondary




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       Impingement Syndromes
             Subacromial bursitis
             Rotator cuff tendonitis
             Bicipital tendonitis
             AC arthritis
             Rotator cuff tear




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       Impnigement : Anatomy




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       Acromion Morphology




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       Impingement : Supraspinatus




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       Impingement :Hx & Px
             Repetitive overhead use of arm
             Swimmers,pitchers
             painful arc
             impingement signs
             decreased ROM active vs. passive
             pain with resisted motion



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       Impingement : treatment
             Avoidance of offending activity
             Physiotherapy
             NSAIDS
             Corticosteroid injection
             Surgery : Subacromial decompression




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       Impingement : Imaging
             Xrays : often normal
             Xrays : shape of acromion
             Arthrogram
             MRI
             MSK Ultrasound




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       MRI ROTATOR CUFF




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       Impingement :Surgery
             Arthroscopic vs open decompression
             Cuff repair
             Excision outer end of clavicle




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       Impingement : Acromioplasty




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       Rotator Cuff Repair




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       Frozen Shoulder
             primary vs. secondary
             prolonged stiffness
             usually self-limited
             lasts up to 2 years
             physio/injection manipulation
             benign neglect



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       RA Shoulder
             usually obvious diagnosis
             joint and tendon damage
             steroid injections
             synovectomy
             Total shoulder arthroplasty




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       OA & AVN
             uncommon
             end stage can be treated by
              arthroplasty
             AVN risk factors




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       OA SHOULDER




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       Tumors
             primary relatively rare
             always think of metastatic disease in
              patients > 50
             night pain
             Xray : bone destruction




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       Tumors




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posted:4/15/2008
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