Shoulder Injuries Surgical Consideration John F. Meyers, M.D.

Fractures

Clavicle Fractures Surgical Indications Rare Tenting or Breaking Skin Marked Comminution Surgical Indications Rare Tenting or Breaking Skin Marked Comminution

Scapular Closed Treatment

Glenoid Restore Stability

Acromioclavicular Seperations Grade 1 Grade 2 Grade 3 Grade 4 Grade 1 Grade 2 Grade 3 Grade 4

Epiphyseal Fracture of Clavicle

Shoulder Impingement Syndrome

Definition – Neer A Spectrum of Diseases the result from an impingement of the Rotator Cuff, the overlying Subacromial Bursa, and occasionally the Tendon of the Biceps against the anterior edge of the Acromion and it’s associated Coracoacromial Arch

Impingement Positions Functional position is forward flexion not Abduction (Neer) Forward Flexion with Internal Rotation -> Greater Tuberosity rotates under Coracoacromial Arch Repetitive Adduction -> Coracoid Process Impingement Functional position is forward flexion not Abduction (Neer) Forward Flexion with Internal Rotation -> Greater Tuberosity rotates under Coracoacromial Arch Repetitive Adduction -> Coracoid Process Impingement

Classic Impingement Lesion Neer JBJS – 1972 Stage 1 –Less than age 25 –Edema & Hemorrhage Stage 2 –Age 25 – 40 –Fibrosis & Tendinitis Stage 3 –Greater Than Age 40 –Bone Spurs & Tendon Rupture Stage 1 –Less than age 25 –Edema & Hemorrhage Stage 2 –Age 25 – 40 –Fibrosis & Tendinitis Stage 3 –Greater Than Age 40 –Bone Spurs & Tendon Rupture

Acromial Morphology Bigliani, et al – 1983 Type 1 (Flat) – 0% Cuff Tears Type 2 (Curved) – 20% Cuff Tears Type 3 (Hooked) – 80% Cuff Tears Type 1 (Flat) – 0% Cuff Tears Type 2 (Curved) – 20% Cuff Tears Type 3 (Hooked) – 80% Cuff Tears

Classification of Rotator Cuff Pathology Compressive Failure Tensile Failure Acute Traumatic Tears Calcific Tendinitis Compressive Failure Tensile Failure Acute Traumatic Tears Calcific Tendinitis

Acute Traumatic Tears Mechanisms of Injury Active Abduction Against Resistance Forced Adduction Acute Traumatic Dislocation Active Abduction Against Resistance Forced Adduction Acute Traumatic Dislocation * May have predisposing impingement or tensile rotator cuff disease

Tensile Failure Failure during eccentric contracture Undersurface Tear (inside -> Outside) Common in throwing athletes Often no Subacromial Impingement at Surgery Failure during eccentric contracture Undersurface Tear (inside -> Outside) Common in throwing athletes Often no Subacromial Impingement at Surgery

Surgical Treatment Arthroscopic Debridement Alone Arthroscopic Debridement & Acromioplasty Arthroscopic Acromioplasty & Mini- Open Repair Classic Open Repair Arthroscopic Debridement Alone Arthroscopic Debridement & Acromioplasty Arthroscopic Acromioplasty & Mini- Open Repair Classic Open Repair

Arthroscopic Debridement Incomplete Tears Without Impingement Calcific Rotator Cuff Tendinitis Without Impingement Incomplete Tears Without Impingement Calcific Rotator Cuff Tendinitis Without Impingement

Arthroscopic Debridement & Acromioplasty Incomplete Rotator Cuff Tear & Impingement Complete Rotator Cuff Tears & Impingement (Primary Goal is Pain Relief) Incomplete Rotator Cuff Tear & Impingement Complete Rotator Cuff Tears & Impingement (Primary Goal is Pain Relief)

Arthroscopic Acromioplasty & Mini-Open Repair Small, Complete, Easily Repairable Lesion Physically Activew Patient with Symptomatic Weakness Small, Complete, Easily Repairable Lesion Physically Activew Patient with Symptomatic Weakness

Classic Open Repair Acute Traumatic Tears Failed Arthroscopic Debridement Acute Traumatic Tears Failed Arthroscopic Debridement