1. Adhesive Capsulitis (Frozen Shoulder)
Medical ppt

2. Definition
A disorder in which the shoulder capsule becomes inflamed and stiff, greatly restricting motion and causing pain.
The etiology is unknown (injury or trauma, autoimmune).
Characterized by progressive pain and stiffness which usually resolves spontaneously after 18 months.
Movement of the shoulder is severely restricted, pain is worse at night.

3. Slight wasting, some tenderness. Pain (gradual onset)
Clinical Features
Age 40-60, more in females
Slight wasting, some tenderness.
Pain (gradual onset)
Stiffness or decrease in motion.
External rotation (most severely inhibited)
Internal rotation.
Abduction.

4. Radiology X-ray: Arthrography:
Osteoporosis of the proximal humerus (decreased bone density)
Arthrography:
Shows a contracted joint
Dramatic decrease in the injected contrast material.
Loss of normally loose dependent folds of the capsule.

5. Differential Diagnosis
Post-traumatic stiffness (maximal at the start, gradually lessens)
Disuse stiffness
Regional pain syndrome (associated with MI, stroke)

6. Treatment
self-limiting: it usually resolves over time without surgery. Movement is regained gradually but may not return to normal
Conservative:
Analgesics
Heat therapy and exercise(physiotherapy)
Corticosteroid injection.
Manipulation under anesthesia hastens recovery.
Operative Treatment
Arthroscopic division of the interval between supraspinatous and infraspinatous (improve the range of movement).

7. Shoulder Instability (Dislocation)

8. Occurs when the humerus separates from the scapula at the glenohumeral joint. The glenoid socket is very shallow and the joint is held secure by the fibrocartilaginous glenoid (labrum) and the surrounding ligaments and muscles.

9. Types
Anterior instability.
Posterior instability.
Multidirectional instability.

10. Anterior Instability Most common. (~95%)
50% under 25 yrs, 50% develop recurrency (the labrum and capsule are detached from the anterior rim of the glenoid)
Occurs as a sequel to acute anterior dislocation of the shoulder, with detachment or stretching of the glenoid labrum and capsule.
Mechanism:
abduction, external rotation, and extension.
falling on outstretched hand, forcing the arm into abduction and external rotation
It can result in damage to the axillary artery.
Recurrent dislocation 
trivial trauma.
Between episodes shoulder looks normal.

11. Approach
Hx: severe pain, limitation of movement, anterior bulging, Hx of trauma. This pathology limits many activities, including overhead arm motions, external rotation, and, thus, physical or athletic activities.

12. Examination shoulder drawer sign
the examiner manually assesses translation of the humeral head in the glenoid fossa. The humeral head is grasped in one hand, and the clavicle and scapula are stabilized in the other as the examiner pushes anteriorly and posteriorly.
Compared with the unaffected shoulder, the affected shoulder often demonstrates increased laxity.
Apprehension test
The arm is placed in abduction, extension, and external rotation while stressing it in anterior translation. If the patient becomes apprehensive and reports pain, this is considered a positive finding.

13. Humeral head anteriorly.
X-ray findings
Humeral head anteriorly.
Axial view is diagnostic. (even for sublaxation).It shows the humeral head riding on the anterior lip of the glenoid.
AP view with the upper arm internally rotated may show Hill-Sachs lesion if recurrent.
Rule out associated humeral neck fracture.
Hill-Sachs lesion :
Depression in the posteriolateral part of the humeral head.
Caused by recurrent forcing of the head of humerus against the anterior glenoid rim (damage to the bone)

14. MRI of anterior inferior labral tear
The Bankart lesion (detached glenoid labrum)
Deformity of the humeral head
MRI of anterior inferior
labral tear

16. Hill-Sachs Lesion

17. Treatment
Reduction:
Most techniques are facilitated by the following 2 maneuvers:
Flexion of the elbow 90° to relax the biceps tendon
External rotation of the humerus, which releases the superior glenohumeral ligament and presents the favorable side of the humeral head to the glenoid fossa
Signs of a successful reduction include the following:
Palpable or audible clunk
Return of rounded shoulder contour
Relief of pain
Increase in range of motion
Stimson Maneuver, Scapular Manipulation, External rotation method, Traction and counter traction

18. Surgery Indications: Types of operation:
Frequent dislocations, esp if painful
A fear of recurrent dislocation sufficient to prevent participation in everyday activities.
Types of operation:
Re-attachment of the glenoid labrum (Bankart)
Shoretening and tightening of the anterior capsule and muscles (Putti-Plat)
Reinforcement of the antero-inferior capsule using adjacent muscles (Bristow)

19. Posterior Instability

20. Due to violent jerk in an unusual position
Rare (5%)
Due to violent jerk in an unusual position
If recurrent, it is almost always a sublaxation, with the humeral head riding back on the posterior lip of the glenoid.
Mechanism:
Abduction, flexion, and internal rotation.
Etiology:
Direct trauma.
Epileptic seizure, Electric shock.

21. Pathology is the same as the anterior one but the capsule is torn posteriorly.
Approach same as anterior dislocation.

22. Diagnosis: Treatment: Reduction Conservative Surgery
X-rays
CT scans
Treatment:
Reduction
(Apply gentle, prolonged axial traction on the humerus. Then add gentle anterior pressure while coaxing the humeral head over the glenoid rim. Slow external rotation may be needed)
Conservative
muscle strengthening exercises and voluntary control of the joint
Surgery
indicated only if disability is marked and there is no gross joint laxity.

24. Multidirectional Instability

25. Associated with capsular and ligamentous laxity, and sometimes with weakness of the shoulder muscles.
The patient complains of the shoulder going out of the shoulder with remarkable ease.
Alternating episodes of anterior and posterior sublaxation or dislocation.
Muscle strengthening exercises and training in joint control are helpful.

26. Thank you! Good luck tomorrow! Done by: Athar shibli Medical ppt