Docstoc

Dr._Martin

Document Sample
Dr._Martin Powered By Docstoc
					Shoulder and Soft Tissue



           Tammy L. Martin, MD
         Chief, Orthopedic Surgery
       Boston VA Healthcare System
Assistant Professor, Harvard Medical School
Boston VA Healthcare System
Conflicts of Interest:
        NONE
                Shoulder
• Amazing joint: unique anatomy, complex
  function
• Allows significant motion for positioning of
  hand in space
• Trades stability for mobility
• Not designed as weight-bearing joint
• Limited soft tissue support
• Subject to overuse/misuse
              Shoulder Pain
• Common complaint
   (35% of patients 25-75 years
     old have complaints)
• Most can be diagnosed with
  history, physical examination
  and x-rays
• Majority with atraumatic
  shoulder pain can be
  managed without surgery
• Surgery often needed for
  large rotator cuff tears, end-
  stage arthritis
             Anatomy
• Large ball, small socket
• Inherently unstable (golf ball on tee),
  most frequently dislocated large joint
• Humeral articular surface 3 x glenoid
• Labrum deepens glenoid by 50%
• Only bony link of upper extremity to
  axial skeleton is through AC joint
        What is the Rotator Cuff?
              Group of four
              muscles deep
 Deltoid      within the shoulder
              Layer beneath the
              deltoid
              The rotator cuff
              muscles assist in
              elevating and
              rotating the
Superficial
muscles       shoulder              Deep muscles
        Rotator Cuff
Rotator Cuff Function

 –Humeral Head Depressor

 –Compressor Effect of cuff pull
  centers humeral head

 –Abduction and External Rotation
    Physical Examination
• Clinical History

• Inspection/observation

• Range of Motion

• Palpation/Bony Architecture

• Soft Tissue Architecture
     Physical Examination
• Motor and Neurovascular Examination

• Stability

• Cervical / elbow

• Special Tests
        Physical Examination
•   Visual inspection
•   ROM, strength, palpation
•   Impingement tests
•   Cervical
•   NV testing
•   AC Joint
•   SLAP lesion
•   Biceps
          Exam: Inspection
• Compare symmetry

• Atrophy

• Scars

• Scapular winging

• Skin lesions

• Need patient properly disrobed
         Exam: Palpation
•   AC joint
•   SC joint
•   Coracoid process
•   Biceps tendon
•   Acromion
•   Rhomboids / trapezius
•   Cervical spine
    Exam: Range of Motion
•   Active and passive
•   Forward flexion (0 - 180)
•   Abduction (0-180)
•   External / Internal rotation (0-90)
•   Apley scratch test (abd/ER, add/IR)
•   Combination ranges
•   Cervical spine motion (flexion-
    extension, rotation, lateral bending)
Shoulder Instability:
   Dislocation
         Exam: Strength
• Compare both shoulders
• ‘Empty can test’ - isolated
  supraspinatus
• External rotation - infraspinatus, teres
• Internal rotation, ‘lift-off test’ -
  subscapularis
• Deltoid, biceps, triceps, distal upper
  extremity
Evaluation of Shoulder Pain
Differential Diagnosis
  –Intrinsic Causes
     • Glenohumeral
     • Periarticular

  –Extrinsic Causes
    • Secondary referral of pain
Impingement Syndrome
• Primary Impingement
  – Acromial hook
  – AC arthritis with spur
  – Tuberosity displacement after
    fracture
• Secondary Impingement
  – Anterior instability
  – Cuff weakness, capsular tightness
Impingement Syndrome
• Impingement and rotator cuff tears
  are increasingly common in
  throwing / overhead activities
• Secondary Impingement
   –Partial rotator cuff tears
   –Subtle anterior shoulder
    instability
     Impingement/Tendinopathy
• Conservative
  – NSAIDS, injections, ice, rest
  – Physical therapy
    • periscapular and cuff strengthening
    • capsular stretching
    • Modalities
Subacromial Decompression

• Conservative
  – NSAIDS, injections, ice, rest
  – Physical therapy
    • periscapular and cuff strengthening
    • capsular stretching
    • Modalities
 Rotator Cuff Tears (RCT’s)
• Common with
  advancing age

• Almost always
  initially involve the
  supraspinatus (one
  of the four rotator
  cuff muscles)

• May be traumatic or
  atraumatic in
  etiology
      Incidence of RCT’s
• Not all tears are
  symptomatic             Age        Prevalence
• Tears will never heal
• Asymptomatic tears      <40        0%
  often get larger and
                          40-60      4%
  may become
  symptomatic             >60        28%
• Surgery usually
  reserved for
  symptomatic tears
                          MRI – asymptomatic
                          patients
Results of Rotator Cuff Repair
 • Similar whether Open, Mini-open or
   Arthroscopic

 • Improved strength

 • Improved ROM

 • Patient satisfaction 88% – 98%
  Shoulder Arthroplasty
• 3- or 4-part humeral head
  fractures (TSA or hemi-
  arthroplasty)
• Primary osteoarthritis
• Rheumatoid arthritis
• End-stage cuff arthropathy
  (constrained prosthesis)
End-stage Cuff Arthropathy
Reverse Shoulder
   Prosthesis
Total Shoulder Prosthesis
      Complications of TSA
•   10-16% mean complication rates
•   Component Loosening
•   Instability
•   Peri-prosthetic / post-op fractures
•   Rotator cuff tears
•   Neural injury
•   Infection
•   Deltoid dysfunction
    Complications of Reverse
          Prosthesis
•   6 - 50%
•   Scapular notching
•   Hematoma
•   Glenoid dissociation
•   Glenohumeral dislocation
•   Infection
•   Loosening
•   Nerve injury
     Post-op Arthroplasty
           Function
• Improved strength: Fair to Good
• Improved pain (compared to pre-op
  scores) good to excellent in 90%
• Improved function (only slight activity
  restriction, able to do overhead activity)
• Improved ROM
   – FF (30 - 40 degrees)
   – ER (25 degrees)
     Restrictions after TSA

•   Repetitive heavy lifting
•   Contact sports (boxing)
•   Heavy pushing/pulling
•   Jarring activities (hammering)
      Shoulder Disability
       Questionnaires
• DASH (Disabilities of the Arm, Shoulder,
  and Hand) - effect on physical function,
  symptoms
• ASES (American Shoulder and Elbow
  Surgeons) Shoulder Outcome Score -
  functional measures, pt and physician
• Constant shoulder score - compares
  shoulder function before and after treatment
• SPADI (Shoulder Pain and Disability Index)
      Shoulder Disability
       Questionnaires
• SANE (Single Assessment Numeric
  Evaluation)

• UCLA Shoulder Score

• WOOS (Western Ontario Osteoarthritis
  of the Shoulder) Index

• Shoulder Activity Level
         AMA Guidelines
• American Medical Association’s Guides to
  the Evaluation of Permanent Impairment

• Sixth edition

• Due to inconsistencies in application of
  criteria, upon rating review, 80% found to
  be erroneous (89% too high)

• Requires MMI (maximal medical
  improvement)
 Ideal Assessment Method
• Objective (ROM, strength, scars, hx of injury)

• Accounts for functional limitations

• Measures pain

• Incorporates radiologic and surgical findings

• Simple

• Consistent among examiners
THANK YOU

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:3
posted:10/23/2010
language:English
pages:41