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

3. Fractures

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

6. Scapular Closed Treatment

10. Glenoid Restore Stability

12. Acromioclavicular Seperations Grade 1 Grade 2 Grade 3 Grade 4 Grade 1 Grade 2 Grade 3 Grade 4

15. Epiphyseal Fracture of Clavicle

16. Shoulder Impingement Syndrome

17. 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

18. 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

19. 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

22. 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

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

32. 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

33. 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

34. 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

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

36. 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)

37. 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

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