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Shoulder ProblemsShoulder Problems

FracturesFractures

InstabilityInstability

ImpingementImpingement

MiscellaneousMiscellaneous

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AnatomyAnatomy

BonesBones Joints / LigamentsJoints / Ligaments MusclesMuscles NeurovascularNeurovascular

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AnatomyAnatomy

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AnatomyAnatomy

AnteriorAnterior

PosteriorPosterior

SupraspinatusSupraspinatus

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AnatomyAnatomy

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Neurovascular AnatomyNeurovascular Anatomy

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Anatomy:JointsAnatomy:Joints

AcromioclavicularAcromioclavicular GlenohumeralGlenohumeral SternoclavicularSternoclavicular ““Scapulothoracic”Scapulothoracic”

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Shoulder problems : HistoryShoulder problems : History

Onset,duration,locationOnset,duration,location ??trauma??trauma radiation of painradiation of pain ?C-spine problems?C-spine problems instability,”dead arm”instability,”dead arm” repetitive userepetitive use

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Physical ExaminationPhysical Examination

deformity deformity egeg AC sep’n AC sep’n ROM passive & activeROM passive & active Impingement testsImpingement tests Instability testsInstability tests neurovascular examneurovascular exam

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Shoulder ProblemsShoulder Problems

F rac turesNeer Class ification

D is locationsA M B R I & T U B S

Inflam m ationC alc ificS eptic

A cute P ain? T raum a

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Trauma !!Trauma !!

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FracturesFractures

ClavicleClavicle Proximal HumerusProximal Humerus Scapula / GlenoidScapula / Glenoid

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Clavicle FracturesClavicle Fractures

CommonCommon Most heal uneventfullyMost heal uneventfully Figure of 8 x 6 weeksFigure of 8 x 6 weeks Beware of high energy ie MVABeware of high energy ie MVA Assoc ‘d soft tissueAssoc ‘d soft tissue

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CLAVICLE FRACTURECLAVICLE FRACTURE

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Clavicle Fractures : Clavicle Fractures : Figure 8 bandageFigure 8 bandage

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Proximal Humerus FracturesProximal Humerus Fractures

Neer- 4 partsNeer- 4 parts Vascularity of articular fragmentVascularity of articular fragment Displacement > 1 cmDisplacement > 1 cm Angulation > 45 degreesAngulation > 45 degrees Xray vs. CT scanXray vs. CT scan Interobserver variabilityInterobserver variability

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Fractures : The Four PartsFractures : The Four Parts

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FracturesFractures

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Proximal Humerus FracturesProximal Humerus FracturesTreatmentTreatment

Undisplaced & 2-part : SlingUndisplaced & 2-part : Sling 3- part : ORIF3- part : ORIF 4- part : Prosthesis 4- part : Prosthesis

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4 PART FRACTURE4 PART FRACTURE

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NEER NEER PROSTHESIS PROSTHESIS

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3 PART FRACTURE3 PART FRACTURE

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ORIF 3 PARTORIF 3 PART

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Fractures :Scapula / GlenoidFractures :Scapula / Glenoid

RareRare Most treated conservativelyMost treated conservatively Intraarticular displacement may need Intraarticular displacement may need

ORIFORIF

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Shoulder InstabilityShoulder Instability

Traumatic vs. HabitualTraumatic vs. Habitual Unidirectional vs. MultidirectionalUnidirectional vs. Multidirectional Unilateral vs. BilateralUnilateral vs. Bilateral

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Anterior Shoulder InstabliityAnterior Shoulder Instabliity

Hx of significant traumaHx of significant trauma Very PainfulVery Painful Most commonMost common Nerve injury Nerve injury esp.esp. axillary axillary Xray : Hill-Sachs defectXray : Hill-Sachs defect

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The “Y” lateral XrayThe “Y” lateral Xray

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The “Y” lateral XrayThe “Y” lateral Xray

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Bankart and Hill-Sach’s lesionsBankart and Hill-Sach’s lesions

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Anterior Shoulder InstabilityAnterior Shoulder Instability

Needs urgent reductionNeeds urgent reduction Muscle relaxation,traction,patienceMuscle relaxation,traction,patience Post reduction exam(neuro) & XrayPost reduction exam(neuro) & Xray Gilchrist slingGilchrist sling Tell patient recurrence riskTell patient recurrence risk recurrent dislocation requires surgeryrecurrent dislocation requires surgery

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Anterior dislocation ;reductionAnterior dislocation ;reduction

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Anterior Shoulder InstabilityAnterior Shoulder Instability

Surgery involves repair of torn anterior Surgery involves repair of torn anterior structuresstructures

Bankart lesionBankart lesion High success rate with several different High success rate with several different

proceduresprocedures

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Anterior Shoulder InstabilityAnterior Shoulder Instability

TraumaticTraumatic UnidirectionalUnidirectional BankartBankart SurgerySurgery

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Multidirectional InstabilityMultidirectional Instability

anterior,posterior,inferioranterior,posterior,inferior voluntaryvoluntary atraumaticatraumatic ligament laxityligament laxity some are assoc’d with psychological some are assoc’d with psychological

problemsproblems

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Multidirectional InstabilityMultidirectional Instability

AtraumaticAtraumatic MultidirectionalMultidirectional BilateralBilateral RehabilitationRehabilitation Inferior Capsular Shift (RARELY)Inferior Capsular Shift (RARELY)

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Acromioclavicular SeparationsAcromioclavicular Separations

Hockey , bikesHockey , bikes Coracoclavicular & Acromioclavicular Coracoclavicular & Acromioclavicular

ligamentsligaments Grade 1-6Grade 1-6 Most treated conservativelyMost treated conservatively Late excision of outer end of clavicleLate excision of outer end of clavicle

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The Clavicular LigamentsThe Clavicular Ligaments

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Acromioclavicular LigamentsAcromioclavicular Ligaments

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Inflammation:Calcific TendonitisInflammation:Calcific Tendonitis

Acute occ. severe painAcute occ. severe pain Mimics infectionMimics infection Marked decrease ROMMarked decrease ROM Xray : Fluffy density near greater Xray : Fluffy density near greater

tuberositytuberosity NSAIDSNSAIDS

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Calcific TendonitisCalcific Tendonitis

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InflammationInflammation

SepticSeptic GoutGout RA flare-upRA flare-up

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Shoulder Pain : ChronicShoulder Pain : Chronic

Im pingem ent Syndrom esR otator cuff tendonitis

cuff tearsA C arthritis

O s teoarthritisR heum ato id A rthritis

A V NF rozen S houlder

B enign tum orsM alignant tum ors

prim arysecondary

C hronic S houlder P ain

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Impingement SyndromesImpingement Syndromes

Subacromial bursitisSubacromial bursitis Rotator cuff tendonitisRotator cuff tendonitis Bicipital tendonitisBicipital tendonitis AC arthritisAC arthritis Rotator cuff tearRotator cuff tear

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Impnigement : AnatomyImpnigement : Anatomy

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Acromion MorphologyAcromion Morphology

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Impingement : SupraspinatusImpingement : Supraspinatus

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Impingement :Hx & PxImpingement :Hx & Px

Repetitive overhead use of armRepetitive overhead use of arm Swimmers,pitchersSwimmers,pitchers painful arcpainful arc impingement signsimpingement signs decreased ROM active vs. passivedecreased ROM active vs. passive pain with resisted motion pain with resisted motion

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Impingement : treatmentImpingement : treatment

Avoidance of offending activityAvoidance of offending activity PhysiotherapyPhysiotherapy NSAIDSNSAIDS Corticosteroid injectionCorticosteroid injection Surgery : Subacromial decompressionSurgery : Subacromial decompression

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Impingement : ImagingImpingement : Imaging

Xrays : often normalXrays : often normal Xrays : shape of acromionXrays : shape of acromion ArthrogramArthrogram MRIMRI MSK UltrasoundMSK Ultrasound

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MRI MRI ROTATOR CUFF ROTATOR CUFF

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Impingement :SurgeryImpingement :Surgery

Arthroscopic vs open decompressionArthroscopic vs open decompression Cuff repairCuff repair Excision outer end of clavicle Excision outer end of clavicle

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Impingement : AcromioplastyImpingement : Acromioplasty

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Rotator Cuff RepairRotator Cuff Repair

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Frozen ShoulderFrozen Shoulder

primary vs. secondaryprimary vs. secondary prolonged stiffnessprolonged stiffness usually self-limitedusually self-limited lasts up to 2 yearslasts up to 2 years physio/injection manipulationphysio/injection manipulation benign neglectbenign neglect

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RA ShoulderRA Shoulder

usually obvious diagnosisusually obvious diagnosis joint and tendon damagejoint and tendon damage steroid injectionssteroid injections synovectomysynovectomy Total shoulder arthroplastyTotal shoulder arthroplasty

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OA & AVNOA & AVN

uncommonuncommon end stage can be treated by end stage can be treated by

arthroplastyarthroplasty AVN risk factorsAVN risk factors

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OA OA SHOULDERSHOULDER

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TumorsTumors

primary relatively rareprimary relatively rare always think of metastatic disease in always think of metastatic disease in

patients > 50patients > 50 night painnight pain Xray : bone destructionXray : bone destruction

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TumorsTumors