Transcript of Brett Gemlick, MD SportONE. Review Shoulder Anatomy Describe types of labral injuries Review...
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- Brett Gemlick, MD SportONE
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- Review Shoulder Anatomy Describe types of labral injuries
Review Surgical Techniques Discuss post operative rehabilitation
Return to play
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- Clavicle 1 st bone to ossify, last to fuse (25 y) SC joint only
true joint connecting UE to axial skeleton Scapula GH: greatest ROM
of all joints golf ball on a tee, not ball in socket Provides site
for 17 muscle attach. Acromion: shape and non-fusion predispose for
problems Proximal Humerus RC attachments Bicipital groove
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- Rotator Cuff (RC) Supraspinatus, Infraspinatus, Subscapularis,
& Teres Minor Function: movement & center H.head in glenoid
Long Head of Biceps (LHB) Superior/anterior stability Labrum
Meniscus of GH joint
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- Laxity=symptomatic, passive translation of humeral head ; no
pain Ex: generalized ligament laxity, hx of chronic ankle sprains
Congenital :Im very bendy Some able to sublux/dislocate without
injury Instability=pathologic condition w/excessive translation of
humeral head on glenoid fossa; pain and/or discomfort
Traumatic/Sports related injuries
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- Static: ligaments & tendons Labrum meniscus of shoulder
Cross-sectional anatomy, micro- vascularity, and attachments
similar to knee meniscus (Cooper 1992) capsule and ligaments RC
passive tension neg. intra-articluar pressure (vacuum) Dynamic:
muscle contraction RC and LHB contraction Scapular retractors
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- Trauma - dislocations of shoulder may cause isolated or
extensive labral injury (Mazzocca 2011) Anterior labral tear or
Bankart lesions Posterior labral tears or reverse Bankhart lesion
Superior Labrum Anterior and Posterior (SLAP) tears
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- Overhead throwing/hitting athletes Long head of biceps anchor
at superior labrum applies traction during overhead throwing,
especially during cocking and deceleration phase (Yeh 2007)
peel-back mechanism during cocking phase Typically SLAP tears
www.ptsmi.org
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- Global Laxity Repeated shoulder subluxations with increased
capsular laxity may result in blunting or tearing of labrum
www.rpocenter.co m
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- Bruce Springsteen Born in the USA
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- History Important Details / HPI Pain description (location,
provocative actions, etc) Acute vs. chronic, frequency With c/o
instability: subluxation v. dislocation self-reduced v. trip to ER
for closed reduction with conscious sedation Direction of
subluxation mechanism of injury temporary numbness/tingling hand
dominance Mechanical symptoms: clicking, catching, etc.
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- OBriens Test SLAP tears or AC injury Apprehension/Relocation
Anterior instability/labral injury Load and Shift
Anterior/Posterior instability Sulcus Sign Inferior instability
Janke test posterior instability Note: MDI patients will likely
have multiple positive tests
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- OBriens Test Apprehension Test
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- Load and Shift Test Sulcus Sign
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- Plain films: AP, outlet, grashey, & AXILLARY! Cannot truly
diagnose dislocation or prove reduction without axillary view Bony
Bankart or Hill Sachs lesions MRI Arthrogram Labrum and capsule
damage seen better w/ dye Bony edema from osseous injury seen that
might not show on plain film
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- Labral Tears MRI arthrogram: 89% sensitive, 91% specific, and
90% accurate (Bencardino 2000) Non-contrast MRI vs MRI Arthrogram
(Sheridan 2014) Non-contrast MRI: accuracy 85%, sensitivity 36%,
PPV 13% MRI Arthrogram: accuracy 69%, sensitivity 80%, PPV 29%
Bankart Tear injury to the labrum at the point of the IGHL (90%)
and MGHL (10%) from the glenoid rim (Solomon) Hill Sachs Lesion
compression fracture at the posterolateral margin of the humeral
head Increased capsular volume Irreversible stretching RC Tears
seen typically in dislocation patients over age 40
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- www.orthoinfo.aaos.org www.crawfordsportsmedicine.com
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- SLAP type DescriptionTreatment IFrayed labrum without
detachmentDebridement IILabrum & biceps anchor detached from
superior glenoid rim Repair IIIBucket-handle tear of superior
labrum wihtout detachement of biceps anchor Debridement
IVBucket-handle tear extending into and splitting biceps Repair
VSLAP II that extends into anterior labrumRepair VISLAP II combined
with parrot-beak type flap tearRepair and debride flap VIISLAP II
extending into MGHL originRepair VIIISLAP II extending
posteriorlyRepair IXCircumferential tear off glenoidrepair
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- Radiologyassistant.nl
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- Anterior Labral Tear www.bacsianh.com Posterior Labral Tear
appliedradiology.com
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- Hill Sachs Lesion
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- Anterior Labroligamentous Periosteal Sleeve Avusion (ALPSA
lesion) Associated with anterior shoulder dislocation
Radiopedia.org/cases/alpsa-lesion
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- The cymbal company Zildjian which was founded in Constantinople
in 1623. Source: American Heritage of Invention & Technology,
Winter 2000
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- Select superior labral tears Long Head of Biceps Tenodesis or
Tenotomy Depends on extent of tear and age of patient Most Labral
Tears Arthrosciopic Labral repair Use of suture anchors or knots to
fixate labrum back to glenoid rim Often performed in conjunction
with capsulorrhaphy if capsule is stretched/weakened
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- SURGICAL FINDINGS: 1. Anomalous long head of biceps tendon with
no normal tendon in the intraarticular portion of the joint. There
was what appeared to be an anomalous long head of biceps tendon
running medial to the normal entrance into the joint, and it went
superficial to the joint capsule and headed posteriorly. There was
a band of tissue that appeared to be the middle glenohumeral
ligament attached to the superior labrum. 2. Three hundred sixty
degree labral tear. Good labral tissue. 3. Normal glenoid and
humeral head articular surface. 4. Normal intraarticular
subscapularis tendon. 5. Ninety percent full-thickness
articular-sided supraspinatus tear just posterior to the bicipital
grove 10 mm in AP dimension. 6. Normal posterior cuff. PROCEDURE
PERFORMED: 1. Right shoulder arthroscopy with arthroscopic superior
labral repair. 2. Arthroscopic anterior labral repair. 3.
Arthroscopic posterior labral repair. 4. Arthroscopic rotator cuff
repair.
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- Posterior Bony Bankhart Anterior Bony Bankhart
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- Arthroscopic Remplissage French for to fill in Infraspinatus
used to fill large Hills-Sachs lesion in conjunction with anterior
Bankhart (Merolla 2014) Boileau 2012
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- Algorithm for surgical treatment of anterior shoulder
instability that has failed conservativ e treatment jaaos.org
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- Shoulder immobilizer x 6 weeks keeps arm at side with forearm
across body Ultra-Sling immobilizer (Gunslinger) for posterior
labrum/capsule to protect repair Begin outpatient PT within few
days of surgery PROM only for 6 weeks At 6 weeks, may DC
immobillizer and begin AROM with PT with 5 lb limit ROM limitation
dependent upon location of repair If capsulorrhaphy, will hold PT
start for 2 weeks
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- SLAP Program may vary between PT departments and/or therapists,
but goals same: Early PROM Structured rehabilitation Return to
sport 80-90% athletes return to throwing and contact sports
(uwhealth.org) 72.5% MLB pitchers returned to competition at a mean
of 13.1 months with no significant change in performance (Ricchetti
(2010) 68% elite pitchers returned to play at mean of 12 months;
22% never returned to MLB (Harris 2013)
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- Immobilizer for 6 weeks May shower on post-op day 3 and change
dressing. No ointments or creams. Do not immerse in water until
staples are removed. Physical Therapy 0-3 Weeks Immobilizer at all
times; active hand, active wrist, passive gentle active elbow
exercises started immediately Codman exercises, PROM 0-90 degrees
of flexion and abduction; external rotation in adduction to
neutral; avoid extension of arm behind body for 4 wks No external
rotation in abduction because of peel-back mechanism Immobilizer
when not doing PROM regimen 3-6 Weeks Continue sling and start
progressive PROM to full as tolerated in all planes Begin passive
posterior capsular and internal rotation stretching Begin passive
and manual scapulothoracic mobility program Begin external rotation
in abduction Allow use of operative extremity for light activities
of daily living 6-16 Weeks Continue all stretching and flexibility
programs as above ROM should be full Begin progressive
strengthening of rotator cuff, scapular stabilizers and deltoid At
8-12 weeks biceps resistance and sports/work specific exercises
instituted with goal of normal function at 4 months For Throwing
Athlete Begin interval throwing program on level surface Continue
stretching and strengthening regimen with particular emphasis on
posterior capusular stretching 6 Months Begin throwing from mound 7
Months Allow full velocity throwing from mound Continue
strengthening and posterior capsular stretching indefinitely
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- Who was the last Division 1 college football team to finish the
regular season unbeaten, untied, AND unscored upon? The University
of Tennessee 1939
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- Solomon,D, et al. Extensive Labral Tears Pathology and Surgical
Treatment. Shoulder Instability: A Comprehensive Approach. 36:
426-34.\ Weber, S. DeLee & Drezs Orthopaedic Sports Medicine.
49: 543- 49. Yeh, ML. Stress Distribution in the Superior Labrum
During Throwing Motion. The American Journal of Sports Medicine.
March 2005. 33: 395-401. Burkhart SS. :The Peel-Back Mechanism: its
role in producing and extending posterior type II SLAP lesions and
its effect on SLAP repair and rehabilitation. Arthoscopy. 1998; 14:
637-40. Mazzocca, A..et al. Traumatic Shoulder Instability
Involving Anterior, Inferior, and Posterior Labral Injury: A
Prospective Clinical Evaluation of Arthroscopic Repair of 270
Labral Tears. Am J Sports Med August 2011. vol 39. 8: 1687-96.
Cooper, DE et al. Anatomy, histology, and vascularity of the
glenoid labrum An anatomical Study. J Bone Joint Surg Am, 1992 Jan;
74 (1): 46-52. Nam, E. and S. Snyder. Clinical Sports Medicine
Update. The Diagnosis and Treatment of Superior Labrum, Anterior
and Posterior (SLAP) Lesions. Am J Sports Med. Sept 2003; 5:
798-810.
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- Ricchetti et al. Glenoid labral repair in Major League Baseball
pitchers. Int J Sports Med. 2010 Apr; 31(4): 265-70. Harris et al.
Return to sport following shoulder surgery in the elite pitcher: a
systematic review. Sports Health. 2013 Jul; 5(4): 367-76.
Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum
anterior-posterior lesions: Diagnosis with MR arthrography of the
shoulder. Radiology 214:267 271,2000 Solomon and Devine. SLAP
Tears: Pearls and Pitfalls in Diagnosis and Management. Sports
Medicine Update Jan/Feb 2011. p2-6. Merolla & Porcellini.
Infranspinatus strenght assessment and ultrasound evaluation of
posterior capsulotenodesis after arthroscopic hill-sachs
remplissage in traumatic anterior glneohumeral instability: a
retrosecptive controlled study protocol. Transl Med UniSa. April
2014. 24:; 9: 27-9. Boileau et al. Anatomical and Functional
Results After Arthroscopic Hill-Sachs Remplissage. J Bone Joint
Surg Am, 2012 April 04; 94 (7): 618-626.