Shoulder Problems

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Shoulder Problems

• Fractures
• Instability
• Impingement
• Miscellaneous

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Anatomy

• Bones
• Joints / Ligaments
• Muscles
• Neurovascular

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Anatomy
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Anatomy
Supraspinatus
Anterior
Posterior
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Anatomy
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Neurovascular Anatomy
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AnatomyJoints

• Acromioclavicular
• Glenohumeral
• Sternoclavicular
• Scapulothoracic

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Shoulder problems History

• Onset,duration,location
• ??trauma
• radiation of pain
• ?C-spine problems
• instability,dead arm
• repetitive use

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Physical Examination

• deformity eg AC sepn
• ROM passive active
• Impingement tests
• Instability tests
• neurovascular exam

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Shoulder Problems
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Trauma !!
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Fractures

• Clavicle
• Proximal Humerus
• Scapula / Glenoid

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Clavicle Fractures

• Common
• Most heal uneventfully
• Figure of 8 x 6 weeks
• Beware of high energy ie MVA
• Assoc d soft tissue

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CLAVICLE FRACTURE
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Clavicle Fractures Figure 8
bandage
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Proximal Humerus Fractures

• Neer- 4 parts
• Vascularity of articular fragment
• Displacement gt 1 cm
• Angulation gt 45 degrees
• Xray vs. CT scan
• Interobserver variability

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Fractures The Four Parts
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Fractures
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Proximal Humerus FracturesTreatment

• Undisplaced 2-part Sling
• 3- part ORIF
• 4- part Prosthesis

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4 PART FRACTURE
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NEER PROSTHESIS
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3 PART FRACTURE
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ORIF 3 PART
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Fractures Scapula / Glenoid

• Rare
• Most treated conservatively
• Intraarticular displacement may need ORIF

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Shoulder Instability

• Traumatic vs. Habitual
• Unidirectional vs. Multidirectional
• Unilateral vs. Bilateral

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Anterior Shoulder Instabliity

• Hx of significant trauma
• Very Painful
• Most common
• Nerve injury esp. axillary
• Xray Hill-Sachs defect

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The Y lateral Xray
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The Y lateral Xray
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Bankart and Hill-Sachs lesions
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Anterior Shoulder Instability

• Needs urgent reduction
• Muscle relaxation,traction,patience
• Post reduction exam(neuro) Xray
• Gilchrist sling
• Tell patient recurrence risk
• recurrent dislocation requires surgery

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Anterior dislocation reduction
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Anterior Shoulder Instability

• Surgery involves repair of torn anterior
  structures
• Bankart lesion
• High success rate with several different
  procedures

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Anterior Shoulder Instability

• Traumatic
• Unidirectional
• Bankart
• Surgery

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Multidirectional Instability

• anterior,posterior,inferior
• voluntary
• atraumatic
• ligament laxity
• some are assocd with psychological problems

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Multidirectional Instability

• Atraumatic
• Multidirectional
• Bilateral
• Rehabilitation
• Inferior Capsular Shift (RARELY)

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Acromioclavicular Separations

• Hockey , bikes
• Coracoclavicular Acromioclavicular ligaments
• Grade 1-6
• Most treated conservatively
• Late excision of outer end of clavicle

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The Clavicular Ligaments
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Acromioclavicular Ligaments
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(No Transcript)
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InflammationCalcific Tendonitis

• Acute occ. severe pain
• Mimics infection
• Marked decrease ROM
• Xray Fluffy density near greater tuberosity
• NSAIDS

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Calcific Tendonitis
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Inflammation

• Septic
• Gout
• RA flare-up

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Shoulder Pain Chronic
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Impingement Syndromes

• Subacromial bursitis
• Rotator cuff tendonitis
• Bicipital tendonitis
• AC arthritis
• Rotator cuff tear

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Impnigement Anatomy
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Acromion Morphology
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Impingement Supraspinatus
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Impingement Hx Px

• Repetitive overhead use of arm
• Swimmers,pitchers
• painful arc
• impingement signs
• decreased ROM active vs. passive
• pain with resisted motion

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Impingement treatment

• Avoidance of offending activity
• Physiotherapy
• NSAIDS
• Corticosteroid injection
• Surgery Subacromial decompression

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Impingement Imaging

• Xrays often normal
• Xrays shape of acromion
• Arthrogram
• MRI
• MSK Ultrasound

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MRI ROTATOR CUFF
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Impingement Surgery

• Arthroscopic vs open decompression
• Cuff repair
• Excision outer end of clavicle

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Impingement Acromioplasty
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Rotator Cuff Repair
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Frozen Shoulder

• primary vs. secondary
• prolonged stiffness
• usually self-limited
• lasts up to 2 years
• physio/injection manipulation
• benign neglect

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RA Shoulder

• usually obvious diagnosis
• joint and tendon damage
• steroid injections
• synovectomy
• Total shoulder arthroplasty

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OA AVN

• uncommon
• end stage can be treated by arthroplasty
• AVN risk factors

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OA SHOULDER
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Tumors

• primary relatively rare
• always think of metastatic disease in patients gt
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• night pain
• Xray bone destruction

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Tumors