1. Musculoskeletal Diseases and Disorders: Shoulder Girdle Complex
PTP 521
Musculoskeletal Diseases and Disorders
Spring/Summer 2012

2. Objectives By the end of this presentation, students will be able to:
Identify common bone presentation on radiographs
Identify common positions for radiographic shoulder studies
Differentiate between an MRI, CT, and US of the Shoulder
Discuss common fractures of the clavicle, scapula, and humerus
Discuss necessary information to obtain on a surgical history to assist in clinical decisions for patients with post operative shoulder conditions

3. Epidemiological Data
According to the Centers for Disease Control and Prevention: Nearly 1.5 million Americans went to ER for shoulder injury in 2006

4. Anatomy Review Joints of the shoulder Girdle Acromioclavicular
Sternoclavicular
Scapulothoracic
Glenohumeral

5. AcromioClavicular Joint
AP view
Alignment: distal clavicle aligns with the acromian
Joint should be less than 6 mm wide
Bone density: check distal end for any fractures or osteophytes
Cartilage and Soft Tissue: not evaluated with this view
Greater than 6 then a possible sprain.
Look for trabecular lines for OA

6. Radiographic Imaging: AP View
Anteroposterior positioning
View position of humerus in relation to the glenoid cavity
Clavicle to the acromion

7. Three views: Internal Rotation External Rotation Neutral
What anatomy do you see on the internal differently from external and neutral?
What parts of the scapula overlap the humeral head. It helps to know the position
of the arm when you review shoulder radiographs. You really have to keep the shoulder
Anatomy in mind. These are all normal (no pathology) views.
emedicine.medscape.com/article/ overview

8. Anterior Posterior View of GH joint
Search Strategy
A: alignment
B: bone density
C: cartilage space
S: soft tissue

9. Radiographs: Anterior Posterior External Rotation View
Humerus is in external rotation
View position of humerus in relation to the glenoid cavity
Clavicle to the acromion
Exposes the greater tuberosity more than the lesser tuberosity
home.comcast.net/~wnor/radiographsul.htm

10. Alignment:
Relationship of the humeral head to the glenoid
Is there an overlap by more than 7-8 mm between the superior portion of the humeral head and the inferior surface of the acromian?
Rotator cuff tear: < 7 mm may indicate a subluxation of the humeral head through rotator cuff muscles into the acromian
emedicine.medscape.com/article/ overview

11. Bone Density Look for consistent trabecular lines
Consistent cancellous patterns in both the humeral head and the glenoid
Are there areas of increased or decreased density?
Snow cap indicating avascular necrosis

12. Cartilage Normal cartilage: Soft Tissue:
May want to assess lung as well as the soft tissue that might be seen around the glenoid and humeral head

13. Scapular Y view
Position of the humerus in relation to the glenoid, acromian and coracoid process
True lateral view of the scapula

14. Lateral View or Transcapular View
Alignment: position of the humeral head within the Y
Humeral head should be within the notch
cme.medscape.com/viewarticle/416588_2

15. ALSO Called: Anterior Oblique: Scapular Lateral (Y) view
So, many names, same view
This is important when determining shoulder dislocations. Look for the humeral head to be outside the notch, posterior to or anterior to the Y when the shoulder is dislocated

16. “eye” sign The “eye” sign is just posterior to the glenoid.
If this eye is not present, the anterior glenoid edge will be obliqued by the superior or inferior glenoid edge - which may mask severe defects that only a properly aligned axillary view will reveal. 
If the "eye" is not seen on the axillary view, this shot should be redone.
This view may also show decreased joint space, fractures, osteophytes, dislocations, Hill Sachs and reverse Hill Sachs Lesions.

17. Axial Shoulder
Difficult view as it requires the patient to be in abduction.
Patient sitting, arm in abduction, film cassette below joint.
X-ray beam directed from superior to inferior at an angle of 5-10 dg toward the elbow.
image.asp?Image= jpg&Film=6102&Features=1

18. Variations of the Axillary View:
Lawrence View
Arm abducted to 90 dg
Patient supine
Beam directed inferior to superior with angulation medial and superior through the axilla
West Point View
Arm abducted to 90 dg
Patient prone
Film against the superior aspect of the shoulder
Beam directed inferior to superior angled toward the axilla ~ 25 dg in frontal plane and ~ 25 dg posterior to joint.

19. West Point View
Similar to an Axillary view, patient is prone instead of supine
Determine glenoid fractures

20. CT Scans MRI have virtually replaced them
Will still see them taken to have a reformatted view of a shoulder fracture
Also common to use CT scan to determine if a patient will have a total shoulder or Reverse total shoulder surgery

21. CT Scan of the Shoulder CT scan of a normal shoulder.
For surgeons to consider replacement surgery, the glenoid bone should be at least 2 cm in depth

22. Dysplasia of the shoulder
Posterior aspect of the glenoid did not develop well

23. Lesions of the glenoid fossa
Bankart Lesion
Erosion of the glenoid

24. Arthroscopic Positioning

25. MRI of the
Shoulder through
the posterior portal

26. MRI Images Coronal Oblique Infraspinatus muscle and tendon
fat suppressed T2 wt images and
proton density weighted images
Coronal Oblique
Infraspinatus muscle and tendon
Supraspinatus muscle and tendon
Acromioclavicular joint
Acromion
Glenohumeral joint
Subacromial/subdeltoid bursa
Labrum – superior and inferior portions
wheelessonline.com

27. MRI Images soft tissue around the shoulder joint Deltoid Tendon
stemcelldoc.wordpress.com/.../

28. Sagittal View T1-weighted view. 1. Coracobrachialis muscle
2. Subscapularis muscle and tendon.
3. Humeral head.
4. Coracoid process
5. Deltoid muscle (Anterior part).
6. Coracoacromial ligament.
7. Acromion.
8. Supraspinatus tendon.
9. Infraspinatus tendon.
10. Deltoid muscle (Posterior part).

29. Rotator Interval Triangular space
Triangular space
coracoid process coming between the subscapularis and supraspinatus muscles and tendons.
Floor of the rotator cuff interval is the cartilage of the humeral head
Roof of the rotator cuff interval is the rotator interval capsule, which links the subscapularis and supraspinatus tendons and is composed of two layers: the CHL on the bursal side and the fasciculus obliquus on the articular side.
Fig. 1. —Drawing, according to Gohlke et al.
of rotator cuff interval in sagittal plane,
with superior capsular complex (in green),
bridging subscapularis tendon (SSC),
superior glenohumeral ligament (SGHL),
and long portion of biceps tendon (LPB) and passing
beneath deep fibers of supraspinatus (SSP).
(Courtesy of F. Gohlke, Wuerzburg, Germany)

30. Axial View Axial T2-weighted FATSAT view. (mid shoulder)
1. Deltoid muscle (Anterior part).
2. Biceps tendon, long head.
3. Coracobrachialis muscle.
4. Subscapularis muscle and tendon.
5. Glenoid.
6. Humeral head.
7. Infraspinatus muscle.
8. Deltoid muscle.

31. Ultrasound http://www.biij.org/2006/4/e58/e58.pdf

32. Shoulder Pain:

33. Fractures of the shoulder girdle complex
Clavicle: 75% occur in children under 13
Proximal fracture
Rare, differentiate from epiphyseal injuries
Middle Third fracture- Most common, 80%
Usually displaced upward by pull of the sternocleidomastoid muscle
Distal fracture
Displaced downward by the weight of the arm.

34. MOI: Fall on the lateral aspect of the shoulder
Fall on outstretched arm (FOOSH)

35. To support the weight of the arm. Figure of eight
RX:
Arm sling
For the first 1-2 weeks
To support the weight of the arm.
Figure of eight
Figure of eight bandage, intent is to reduce the motion at the fracture site.
Worn for a period of at least 6 weeks (adults) or 4 weeks (child).
Can use the arm as wanted & symptoms allow.

36. Scapular Fractures 1% of all fractures
High energy: fall or direct blow
Associated Injuries
Ipsilateral rib fractures
Pulmonary trauma
Clavicular fractures
Brachial plexus injuries
Subclavian artery injuries
Classified according to location

37. Scapula: Type I: fractures of scapular body 2
Type II: fractures of apophyseal regions including acromion and coracoid process 3,4
Type III: fracture of superolateral angle including glenoid neck and fossa 1
RX: generally minimal treatment. Surgery only in most drastic, displaced fractures.
Donatelli RA, 1987

38. Scapular Fractures requiring surgery
Acromion or scapular spine fractures with a doward tilting of the lateral fragment and subacromial narrowing
Coracoid fractures that extend into the glenoid fossa
Glenoid rim and intra-articular glenoid fractures associated with glenohumeral instability

39. Rx of Scapular Fractures
Sling 7-10 days
Progressive regimen of pendulum and gentle ROM exercises
Progressive AROM and strengthening exercises

40. Humeral Head Fractures
Fracture Dislocations

41. Proximal:
A. Greater Tuberosity
More commonly seen in older individuals.
B. Lesser Tuberosity
Rare, usually avulsion fractures
C. Neck of the Humerus
Common fractures, transverse, comminuted, impacted
D. Shaft of the Humerus
MOI: significant force applied directly or indirectly to shoulder region
Rx: depends upon the type of fracture, age of the patient

42. Fractures Associated with Shoulder Dislocations
Hill-Sachs lesion:
depression fracture of the posterior/lateral humeral head. 
Area of soft cancellous bone which is compressed against the glenoid rim. 
Occurs in 77% of traumatic anterior dislocations

43. Bankart Lesion
Defined as a detachment of the labrum from the glenoid rim
occur in 87% of the traumatic dislocations
the most common reason for recurrent instabilities

44. Quality of the Tissue Specifics of the Case:
Good tissue quality: heal faster, less functional issues
Poor tissue quality: will the repair hold, takes longer to heal, more functional deficits after surgery
Specifics of the Case:
Did it involve the Biceps Tendon or not?
Removal of any bone?
Other?

45. Rotator Cuff Dysfunction Resulting in Impingement
Key pathophysiological factors
Primary or secondary impingement
Tensile overload
Macrotraumatic tendon failure
Posterior or undersurface impingement
Key Muscles and Force Couples
Deltoid Rotator cuff force couple
Deltoid force:
Rotator Cuff force:
Trapezius and Serratus anterior
Anterior posterior rotator cuff force couple
Concavity-compression mechanism

46. Rotator Cuff Impingement
Primary Compressive Disease: Primary Impingement
Compression of rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, coracoacromial ligament, coracoid or AC joint
Subacromial space
Normals:
6mm-14mm
Patients with shoulder pain:
7mm-13mm

47. Neer Classification
Stage I: characterized by edema, inflammation, hemorrhage in the subacromial space. Swelling is responsible for the impingement
Risk Factors: age 25 or less
SX: dull ache in the shoulder after activity, pain may interfere with ADL’s

48. Signs: painful arc in abduction - between 60 and 120 dg, pain free
PROM, resisted tests are strong but painful for abduction
Palpation: tender over the greater tuberosity and the anterior edge of the acromian
Special tests: + Neer impingement test, + Kennedy and Hawkins test.
This stage is easy to reverse if the person rests from aggravating activities and changes some work or play postures, strengthens weak muscles

49. Stage II:
Characterized by aggravation of the subacromial contents creating a thickness in the bursae and fibrosis of the tendons.
Risk Factors: 25 to 40 years of age
SX and Signs: similar but increased in intensity from Stage I
Impairments: more limitation in the PROM and with Hawkins and Kennedy test there is a catching sensation with the return from an elevated position.
More difficult to reverse than Stage I

50. Stage III: More complicated: Risk Factor: 40 years of age or greater
get a partial or full thickness tendon tear,
changes in the bony configuration of the humeral head and acromion,
osteophytes
Risk Factor: 40 years of age or greater
SX: increase in intensity of symptoms, interferes with daily activities
Signs: AROM more limited than PROM, resisted tests show weakness in abduction and external rotation

51. X-Rays: cystic changes in the greater tuberosity, underside of the acromian or at the AC joint
RX: surgery if conservative treatment doesn’t work. Repair of the torn muscles would occur with all of the surgical options.
Surgical Options:
1. coracoacromial ligament resection
2. anterior acromioplasty
3. distal clavicle resection (Mumford procedure)
4. AC joint inferior osteophyte resection

52. Mechanical Impingement:
Abnormal shape of the acromion.
3 types of acromion, flat, curved and hooked.
There is a close association with a hooked acromion (70%) with full thickness rotator cuff tears; 80% association with impingement syndrome

53. Secondary Compressive Disease
Due to underlying instability of the GH joint
Anterior instability – overhead athletes, throwing athletes
Increase in anterior translation, biceps tendon and rotator cuff become impinged
Continual loss of GH stability
Leads to rotator cuff tears

54. Tensile Overload Tendinosis injuries Degenerative process
Repetitive intrinsic tension overload
Occurs during deceleration and follow through
High load placed on posterior rotator cuff muscles
Pathological changes of angiofibroblastic hyperplasia – early tendon stages, progresses to tears
Tendinosis injuries
Degenerative process

55. Macro traumatic Tendon Failure
Single traumatic event or a previous traumatic event
Forces are greater than the tendon can handle
Normal tendons don’t tear
30% damaged to produce a substantial reduction in strength
Full thickness tears
Bony avulsions
May have had repeated microtraumatic insults and degeneration over time
Failure over one heavy load

56. Posterior impingement
Undersurface
In 90 dg of abduction and 90 dg of Ext rotation
Supraspinatus tendon and infraspinatus tendon rotate posteriorly and get pinched between the humeral head and the posterior-superior glenoid rim

57. Add anterior translation of the humeral head causes mechanical fraying on undersurface of the rotator cuff tendons
Halbrecht et al studied baseball pitchers with MRI of shoulder
Paley et al studied 41 professional throwing athletes – all had this problem