Presentation is loading. Please wait.

Presentation is loading. Please wait.

The Complex Shoulder Simplified Manish A. Patel, MD, FAAOS Assistant Professor – Eastern Virginia Medical School Chief of Surgery-Southampton Memorial.

Similar presentations


Presentation on theme: "The Complex Shoulder Simplified Manish A. Patel, MD, FAAOS Assistant Professor – Eastern Virginia Medical School Chief of Surgery-Southampton Memorial."— Presentation transcript:

1 The Complex Shoulder Simplified Manish A. Patel, MD, FAAOS Assistant Professor – Eastern Virginia Medical School Chief of Surgery-Southampton Memorial Hospital (757)

2 Overview Most mobile joint in body Most mobile joint in body Most dislocated joint Most dislocated joint Stability Stability –Bony articulation –Ligamentous –Muscular

3 Review of shoulder anatomy Bones Bones –Scapula –Clavicle –Humeral head –Posterior rib cage Joints Joints –Sternoclavicular –Acromioclavicular –Glenohumeral –Scapulothoracic

4 Glenohumeral Joint 25% humeral head surface in contact with glenoid 25% humeral head surface in contact with glenoid Joint space thinning seen with OA Joint space thinning seen with OA Humeral head coverage increased to 75% with glenoid labrum Humeral head coverage increased to 75% with glenoid labrum

5 Labrum Glenoid Labrum Glenoid Labrum –Dense, fibrous structure –Oval –Deepens glenoid fossa –Stability

6 Subacromial Space Bursa Bursa –Subacromial space –Source of pain down arm

7 Rotator cuff muscles Supraspinatus, infraspinatus, teres minor, subscapularis Supraspinatus, infraspinatus, teres minor, subscapularis Form cuff around humeral head Form cuff around humeral head Keeps humeral head within joint (head depresser) Keeps humeral head within joint (head depresser) Abduction, external rotation, internal rotation Abduction, external rotation, internal rotation

8 Physical Exam Visualize from front and back Visualize from front and back Asymmetry Asymmetry –Pts with rotator cuff tears hold shoulder higher Atrophy Atrophy –Sign of chronic glenohumeral joint pathology Effusions Effusions –Shoulder joint can hide a lot of fluid

9 Active range of motion Forward flexion Forward flexion Abduction/adduction Abduction/adduction –Painful arc of abduction – sensitive, not specific External rotation External rotation Internal rotation Internal rotation

10 Passive range of motion Immobilize the scapula to prevent rotation Immobilize the scapula to prevent rotation –Use one arm to push down on shoulder –Use other arm to do the PROM exercises Abduction Abduction Internal and external rotation Internal and external rotation –Have arm at patient’s side and abducted to 90 degrees

11 Physical Exam External Rotation External Rotation –Infraspinatus –Teres Minor

12 Physical Exam Supraspinatus Supraspinatus –45 Degrees from front

13 Physical Exam Impingement Impingement –Greater Tuberosity under acromion

14 Physical Exam Cross Arm Test Cross Arm Test –Specific for AC Joint

15 Biceps Strength Testing Arms outstretched with palms up at level of shoulder Arms outstretched with palms up at level of shoulder Forced supination of hand with elbow flexed at 90 degrees Forced supination of hand with elbow flexed at 90 degrees Can be positive for SLAP Test Can be positive for SLAP Test

16 Etiology of Shoulder Pain Trauma Trauma Overuse Overuse Chronic Chronic Previous Surgery Previous Surgery Instability Instability Neck Pain Neck Pain Infection Infection Dislocation Dislocation Frozen Shoulder Frozen Shoulder

17 Trauma Shoulder Dislocation Shoulder Dislocation Fracture Fracture

18 Treatment Fractures – Not all require surgery Fractures – Not all require surgery Surgical options includes (Rods / Plate / Partial vs complete replacement) Surgical options includes (Rods / Plate / Partial vs complete replacement)

19 Shoulder Dislocation Fast Facts Fast Facts –50 % of ALL dislocations –95 % anterior –85 % caused by trauma recur –Posterior think seizures or direct trauma

20 Shoulder Dislocations Mechanism? Mechanism? –Anterior vs. posterior Forced abduction, external rotation, extension Forced abduction, external rotation, extension Forced adduction, internal rotation Forced adduction, internal rotation

21 Shoulder Dislocations Dislocation vs. Subluxation? Dislocation vs. Subluxation?

22 Shoulder Dislocations Defects following dislocation? Defects following dislocation? –Hill-Sachs –SLAP –Bankart –Rotator Cuff Tear –Fractures

23 Shoulder Dislocations Hill-Sachs lesion Hill-Sachs lesion –Posterior lateral aspect –Compression

24 Shoulder Dislocation Superior Labrum Anteroposterior Lesion (SLAP) Superior Labrum Anteroposterior Lesion (SLAP) –Affects biceps

25 Shoulder Dislocations Bankart Lesion Bankart Lesion –Arthroscopic vs. open –Anterior labrum

26 Instability Unidirectional Unidirectional Multidirectional Multidirectional

27 Shoulder Dislocations Chronic Instability – Increasing laxity due to repeat incidents, trauma, genetics, or neuromuscular deficits Chronic Instability – Increasing laxity due to repeat incidents, trauma, genetics, or neuromuscular deficits –Signs and Symptoms Sport Sport Clicking Clicking Pain Pain Weakness Weakness

28 Overuse Repetitive Motion Repetitive Motion Microtrauma Microtrauma Deconditioning Deconditioning

29 Chronic Pathology Impingement Impingement Biceps Pathology Biceps Pathology Arthritis Arthritis –Trauma or Overuse Rotator Cuff Syndrome Rotator Cuff Syndrome Frozen Shoulder Frozen Shoulder

30 Impingement syndrome Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion (type 3) Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion (type 3) Repetitive overhead motions Repetitive overhead motions Main cause of rotator cuff tendonitis Main cause of rotator cuff tendonitis Can lead to bursitis, partial or full rotator cuff tears Can lead to bursitis, partial or full rotator cuff tears

31 Previous Surgery Rotator Cuff Re-tear Rotator Cuff Re-tear Shoulder Stabilization Shoulder Stabilization

32 RC Tear Rotator Cuff Tear (Most Common) – Night Pain Rotator Cuff Tear (Most Common) – Night Pain Pain Radiating up / down Pain Radiating up / down Numbness Numbness Weakness Weakness Decrease Motion Decrease Motion 50+ age group 50+ age group

33 Radiology for rotator cuff tears Interpret carefully Interpret carefully –34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tears –Abnormal rotator cuff signal after trauma may represent strain rather than tear X-rays X-rays –Look for high riding humeral head Ultrasound Ultrasound –Highly operator dependent MRI MRI

34 Rotator cuff tears

35 Tx of rotator cuff tears Ice, NSAIDs, restrict aggravating motions Ice, NSAIDs, restrict aggravating motions Weighted pendulum Weighted pendulum No arm slings No arm slings Steroid injection Steroid injection Surgery – refer if young pts, full/large tears, dominant arm Surgery – refer if young pts, full/large tears, dominant arm –Best if done within 6 weeks Acromioplasty and debridement Acromioplasty and debridement

36 Injection Subacromial Space Subacromial Space –22 Gauge needle 1.5” –10 cc total vol. –40 mg kenelog –Post placement –Aim for Coracoid GH Joint GH Joint –Spinal needle 3” –10 cc total vol. –40 mg Kenelog –Straight Aim –Posterior placement Beware of Diabetics

37 Treatment Rotator Cuff / Biceps – Good clinical Exam to Start Rotator Cuff / Biceps – Good clinical Exam to Start Conservative Options – PT / Injections / Meds Conservative Options – PT / Injections / Meds Xray and MRI helpful Xray and MRI helpful Surgery (Arthroscopic only way to these days in my opinion) Surgery (Arthroscopic only way to these days in my opinion) Rehab Course Better Rehab Course Better

38 Frozen Shoulder Frozen Shoulder – Diabetics Frozen Shoulder – Diabetics Decrease range of motion in all planes Decrease range of motion in all planes Pain with any motion Pain with any motion age group age group

39 Radiology for adhesive capsulitis X-rays have limited use X-rays have limited use –Might see calcifications or degenerative changes that would lead to frozen shoulder MRI MRI –Enhancement of joint capsule and synovial membrane –4 mm thickening is 70% sensitive and 95% specific

40 Tx of adhesive capsulitis Watchful waiting Watchful waiting –Up to 2 years for resolution –Incomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abduction Steroid injection (2 locations) Steroid injection (2 locations) Manipulation under anesthesia Manipulation under anesthesia Aggressive therapy Aggressive therapy Pain medication Pain medication

41 Biceps tendonitis Inflammation of long head of biceps Inflammation of long head of biceps –Passes through bicepital groove of anterior humerus Usually due to repetitive lifting or reaching Usually due to repetitive lifting or reaching Inflammation, microtearing, degenerative changes Inflammation, microtearing, degenerative changes Up to 10% pts will have spontaneous rupture Up to 10% pts will have spontaneous rupture Popeye deformity Popeye deformity

42 Sx of biceps tendonitis Anterior shoulder pain Anterior shoulder pain Worse with lifting or overhead reaching Worse with lifting or overhead reaching Often pts point to bicepital groove Often pts point to bicepital groove Usually no weakness in elbow flexion Usually no weakness in elbow flexion

43 Exam for biceps tendonitis Bicipital groove tenderness Bicipital groove tenderness Look for subacromial impingement Look for subacromial impingement Tendon rupture Tendon rupture Test biceps strength Test biceps strength Yergason test Yergason test –Elbows flexed with forearms in front –Pt actively resisting external rotation –Tendon may pop out of bicipital groove when downward pressure applied to forearm

44 Ruptured biceps tendon Usually rotator cuff tear also present Usually rotator cuff tear also present Get the “popeye” sign Get the “popeye” sign Rarely get significant weakness Rarely get significant weakness –Brachioradialis and short head of biceps provide 80-85% elbow flexor strength Tx is supportive Tx is supportive

45 Tx of biceps tendonitis Reduce inflammation Reduce inflammation Strengthen biceps muscle and tendon Strengthen biceps muscle and tendon Prevent rupture Prevent rupture Ice, NSAIDs, avoid aggravating motions Ice, NSAIDs, avoid aggravating motions –5-10% risk of rupture with noncompliance Weighted pendulum Weighted pendulum Elbow flexion toning exercises Elbow flexion toning exercises Steroid injection Steroid injection Surgical referral if sx persist >3 months Surgical referral if sx persist >3 months

46 Glenohumeral Osteoarthritis Same risk factors as with OA in other areas Same risk factors as with OA in other areas –Trauma, obesity, age Less common than OA in weight bearing joints or spine Less common than OA in weight bearing joints or spine Pain, stiffness over months to years Pain, stiffness over months to years –Anterior shoulder is most painful area Worse with activity Worse with activity Distinguish from RA, adhesive capsulitis Distinguish from RA, adhesive capsulitis

47 Exam for Glenohumeral OA GH joint line tenderness and swelling GH joint line tenderness and swelling –Just below coracoid process –Use outward and upward pressure –Effusion may be very hard to see Decreased ROM Decreased ROM –External rotation, abduction –Endpoint stiffness Crepitus Crepitus

48 Imaging for glenohumeral OA Joint space narrowing (loss of articular cartilage) Joint space narrowing (loss of articular cartilage) Osteophytes Osteophytes Humeral head sclerosis and flattening Humeral head sclerosis and flattening Club-like deformity Club-like deformity Goat’s Beard on X-ray Goat’s Beard on X-ray

49 Treatment Arthritis – From trauma or genetic Arthritis – From trauma or genetic Conservative – PT (sometimes) / Injections / Meds / Lifestyle modification Conservative – PT (sometimes) / Injections / Meds / Lifestyle modification Surgery – Partial vs Total (Reverse Shoulder) Surgery – Partial vs Total (Reverse Shoulder) Rehab Rehab

50 Glenohumeral Joint Infection Very rare Very rare Increased incidence in diabetics, immuno- compromised patients. Increased incidence in diabetics, immuno- compromised patients. Shoulder looks normal, just bigger. Shoulder looks normal, just bigger. SEVERE pain. Any motion hurts. SEVERE pain. Any motion hurts. Often a fever. Get labs (CBC, blood cultures, ESR, CRP), XR, then: Often a fever. Get labs (CBC, blood cultures, ESR, CRP), XR, then: Get a consult. Get a consult.

51 Ref for Shoulder: Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Journal of American Academy of Orthopedic Surgery, Vol 14, No 6, June 2006, Iannotti, JP et al, Partial-thickness tears of the rotator cuff: evaluation and management, Journal of American Academy of Orthopedic Surgery 1999; 7: Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal of Bone and Joint Surgery (American). 2010;92: Ref for Shoulder: Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Journal of American Academy of Orthopedic Surgery, Vol 14, No 6, June 2006, Iannotti, JP et al, Partial-thickness tears of the rotator cuff: evaluation and management, Journal of American Academy of Orthopedic Surgery 1999; 7: Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal of Bone and Joint Surgery (American). 2010;92:

52 Thank You Manish A. Patel, MD, FAAOS Office: (757) Pager: (757) Cell: (215)


Download ppt "The Complex Shoulder Simplified Manish A. Patel, MD, FAAOS Assistant Professor – Eastern Virginia Medical School Chief of Surgery-Southampton Memorial."

Similar presentations


Ads by Google