The Shoulder & Pectoral Girdle (2)

Imaging

•X-ray shows sublaxation, dislocation, narrow joint space, bone erosion, calcification in soft tissues•Arthrography detecting rotator cuff tears, Bankart lesions found with anterior stability

Imaging •CT scan cuff tears + labral detachments•Ultrasound rotator cuff tears•MRI rotator cuff pathology – instability- osteonecrosis of head of humerus- staging of tumors •Arthroscopy intra articular lesions- detachments of the labrum- capsule & impingement or tears of the rotator cuff

Pathology

Adhesive Capsulitis

•Characterized by progressive pain and stiffness•It usually resolves after about 18 months •The causes remain unknown

Clinical features •The patient, age 40-60 years may give a history of trauma, followed by aching in the arm and shoulder•Pain gradually increase in severity prevent sleeping on the affected side•Stiffness becomes an increasing problem•A frozen shoulder looks quite normal + some wasting•Not much tenderness marked•There is lack of activity and passive movements in all directions

Diagnosis

•When patient is seen exclude: infection, post-traumatic stiffness, diffuse stiffness and reflex dystrophy

Calcification of the Rotator Cuff ( Acute Calcific

Tendinitis)

•Acute shoulder pain may follow deposition of calcium in the supraspinatus tendon

•The cause is unknown

Clinical features

•The condition affects 30-50 year olds following overuse •The pain subsides after few days•During acute stage, the arm is held immobile•Calcification is seen just above the greater tuberosity on an x-ray

Rupture of Long Head of Biceps

•Patient always over 50 years•While lifting, the patient feels something snap in the shoulder & upper arm becomes painful and bruised

•Ask the patient to flex the elbow, you’ll see a prominent lump in lower part of the arm

Impingement Syndrome

•Arises from repetitive compressing or rubbing of the rotator cuff tendons (mainly supraspinatus) under the coracoacromial arch•If arm is abducted and then externally and internally rotated as in cleaning a window, the rotator cuff may be compressed as it comes in contact with the acromion process & coracoacromial ligament •Impingement position ( abduction, slight flexion, internal rotation)

Instability of the Shoulder

•If the humeral head is not held in place, recurrent dislocation or recurrent sublaxation

•In 95% of cases the displacement is anterior•It can also be posterior or multidirectional

Anterior Instability

•It follows acute injury in which the arm is forced into abduction, external rotation, and extension

Posterior Instability

•The condition is due to a violent jerk in an unusual position

•Recurrent posterior instability usually takes the form of sublaxation when the arm is used in flexion and internal rotation

Multidirectional Instability

•The condition is associated with capsular and ligamintous laxity, and sometimes with weakness of the shoulder muscle•Little force is required to displace the joint•Muscle strengthening and training in joint control are helpful

Habitual Sublaxation

•Dislocation can occur more or less spontaneously if there are congenital anatomical abnormalities or sever ligamintous laxity

•The patient can voluntarily sublaxate or dislocate the shoulder, painlessly and reduce it again easily

Tuberculosis

•Constant ache & stiffness lasting many months•Wasting of muscles around the shoulder especially the deltoid

Rheumatoid Arthritis

•The most common joint disease to affect the shoulder•Acromioclavicular erosion discovered on an x0ray of the chest is the first clue of the diagnosis

Osteoarthritis

•Patient is usually aged 50-60 years

•There is a restriction in shoulder movement in all directions•Articular space may be narrowed + osteophyte formation + bone sclerosis

Arthroplasty

•The process of replacing the joint with an artificial joint

Arthrodesis

•Indications : •Paralysis of the scapulohumeral muscles•Infective disorders of the glenohumeral joint•Advanced erosive arthritis with massive disruption of the rotator cuff