SHOULDER INJURIES Orthopaedic Perspective of

SHOULDER INJURIES
Orthopaedic Perspective of Injuries: When Do you Need to Refer
Your Patients to Me
Thomas Loughran, MD
26
SHOULDER INJURIES
An Orthopaedic Perspective When to Refer
Thomas Loughran, MD
MCV Department of Orthopaedic Surgery
Objectives
Recognize common sport medicine
injuries
„ Discuss treatment options
„ Recognize when to treat and when to
refer
„
The Shoulder Joint
•
•
•
•
Complex Range of Motion
Little Bony Support
Stability relies on soft tissue integrity
Non weight bearing joint
27
1
Common Sport Shoulder
Injuries
Fractures
Clavicle, Humerus,
Humerus,
Glenoid,
Glenoid, Scapula
„ Dislocations Glenohumeral,
Glenohumeral, AC joint
with osteolysis
„ Soft tissue tears Rotator cuff, Labral,
Labral,
Biceps, Pectoralis
„
28
2
When to Refer: The Basics
Displaced fractures and dislocations
„ Shoulder Instabilities
„ Persistent shoulder pain
„ When your not comfortable treating
patient
„ When initial treatments fail
„
Common Shoulder Fractures
•
•
•
Proximal Humerus usually seen in
osteoporotic bone 85% are minimally
displaced
Clavicle fall on outstretched hand
common in cyclers
Scapular High energy injuries assoc.
with first rib fxs and hemopneumothorax
29
3
Clavicle Fractures
•
•
•
•
•
35% of all fractures about the shoulder
85% involve middle third of clavicle
In patients under the age of 21 lateral fx
often epiphyseal injury
Non union rare
Assoc. injury laceration of subclavian
vessels, brachial plexus trauma
Minimally
displaced fx
30
4
31
5
Displaced clavicle
fx
Distal Clavicle Fracture
Coracoclavicular
ligaments
Fxdistalclavicle__.jpg
32
6
Clavicle Fractures
No need to refer nondisplaced fxs,
fxs,
minimally displaced fxs in medial or mid
zones Tx with simple sling
„ Displaced fxs,
fxs, lateral zone,
neurovascular, involvement, epipthyseal
fxs,
REFER
fxs,
„
Scapular Fractures
Rare High index suspicion vague
posterior shoulder pain
„ High velocity injury
„ Associated neurovascular injuries
„ Axillary xray to delineate
„ All need to be referred
„
33
7
adult_shoulder_fx_type_scapular_blade.jpg
glenoid fx base.jpg
Scapula fx base
glenoid
34
8
Scapular fx body
Glenoid fractures
Associated with Shoulder Instability
„ Fx that involves more than 25% of
glenoid need ORIF
„
35
9
Glenoid Bony Bankart
Fracture
Glenoid
displaced fx
36
10
CT Glenoid fx
Glenoid Fractures
Most need to be referred
„ Associated with Shoulder Instability and
significant trauma
„ CT often needed to delineate fracture
„ Look for associated scapular fractures
„
37
11
Proximal Humerus Fractures
Most fractures are non displaced and do
not need referal,
referal, need to follow closely
„ Greater tuberosity fxs,
fxs, associated with
rotator cuff injuries
„ Seen in Younger Sportsmen as
Epiphyseal Fxs,
Fxs, not as common in
Adults
„ All displaced Fxs need to be Referred
„
Greater Tuberosity Fx
Displaced Greater Tuberosity
Fx
38
12
Proximal Humerus 3 Part
Fracture
Prox Humerus
Epiphyseal 2 part
fx
Percutaneous pinning
39
13
Instability Lesions of the
Shoulder
•
MOBILITY versus STABILITY
Dislocations of the
Glenohumeral Joint
•
•
•
•
Anterior shoulder dislocations most
common. Tear of ant. capsule
MOIMOI- ext. rotation/abduction
Assoc. PathologyPathology- Glenoid
fxs(Bankart),
fxs(Bankart), Humeral head fxs(Hillfxs(HillSachs),
Nerve injuries, Axillary and
Musculocutaneous
40
14
Anterior inferior shoulder
dislocation
41
15
Natural History of Anterior
Shoulder Dislocations
Under the age of 20 recurrence rate
close to100 percent
„ Under the age of 30 recurrence rate
50%
„ 40% chance of rotator cuff tear with
dislocation in patients over 60yoa
„
Relocation test
42
16
Attenuated anterior capsule
Bony Bankart
lesion
43
17
Hill-Sachs Lesion
Fraying Anterior
Labrum
Hill-Sachs Lesion
44
18
Treatment of Anterior
Shoulder Dislocations- Initial
Trauma
•
•
•
•
•
Reduction
Immobilization in sling for 3weeks
Rotator cuff and scapuloscapulo-rotator muscle
strengthening
Protective Bracing e.g. Sawa Brace
Select group may opt for surgery, West
Point study 80% failure of non operative
pts
Reduction GH Joint
45
19
Tx for recurrent anterior
shoulder dislocation
•
•
•
•
Individualize based on age,
age, activity level,
demands, dominant extremity, assoc.
pathology
Surgery for TUBS lesion (traumatic
unidirectional Bankart)
Bankart)
Operate when glenoid fx makes up more than
20 percent Joint surface
Open repair 4 to 10 % failure rate,
arthroscopic repair 12 to 40 % failure rate
Sling in Internal Rotation
46
20
Brace in Neutral Rotation
47
21
Sawa Brace
Arthroscopic repair
bankart labrum
48
22
Macrotrauma and
Microtrauma
Mechanism of Injury
Acute Anterior Shoulder
Subluxation
•
•
•
•
MOIMOI- ext. rotation force single vs.
repetitive
Seen in over head throwersthrowers- Dead Arm
Syndrome
Due to Anterior Capsular Stretching
Assoc. with Brachial Plexus Stretch
49
23
Exam for Shoulder Instability
•
•
•
Apprehensive testtest- pain anterior with external
rotation and abduction
Relocation testtest- reduction of pain when
posterior force applied to ext.rot.abducted
shoulder
Internal Impingement testtest- posterior shoulder
pain as humeral head impinges on posterior
rotator cuff due to anterior capsular laxity
50
24
Internal Impingement secondary
to anterior instability
Often presents with
posterior shoulder pain
Tight Internal Rotation
51
25
Little League Shoulder
Proximal Humerus
Epiphyseal Fx
Posterior Dislocation of the
Shoulder
•
•
•
•
MOIMOI- forward flexion and internal rotation
force
Patients have difficulty opening doors, doing
pushups, posterior shoulder pain with
weakness of external rotators of shoulder
Lateral and axillary xrays to assess posterior
glenoid lesions
Rehab the key in treatment, Surgical failure
rates up to 50%
52
26
53
27
Posterior
dislocation
Lateral Scapula view
Posterior
dislocation
Axillary View Posterior
Dislocation
54
28
Multidirectional Instability of
the Shoulder(MDI)
•
•
•
•
Shoulder capsule lax in 2 or more
directions sag sign
Generalized laxity of all joints EhlersEhlersDanlos type
Repetitive microtrauma usual cause,
gymnastics, swimming, volleyball,
overhead activity
Voluntary Dislocators
Sulcus Sign
55
29
Sulcus sign Inferior Instability
Treatment of MDI Syndrome
•
•
•
•
Rehab,Rehab,Rehab
Avoid surgery in voluntary dislocators
If surgery neededneeded- Capsular shifts with
plication of capsule with thermo
capsular shrinkage as adjunct is
encouraging
High surgical failure ratesrates- difficulty
finding the true center of shoulder
56
30
GlenoHumeral Instability
Primary GH Dislocation in Athlete need
to refer
„ Recurrent Dislocators Rx Mulifactoral
„ Posterior Instability often missed
„ MDI usually rx non operative r/o
ErhlerErhler-Danlos Syndrome
„
Direct Blow to Shoulder
57
31
Acromioclavicular Instability
•
•
•
•
•
MOIMOI- direct fall on the lateral edge of
acromion,
acromion, fall on out stretched arm
Tenderness at AC joint with or without distal
clavicle elevation
Grades 11-VI higher grades more severe soft
tissue involvement
Grades 11-III do well with sling, ice ,analgesics
, and gentle ROM
Grade 1 lesions can lead to osteolysis of
distal clavicle
58
32
AC Joint Separation
Types 1and 2 can be tx with sling and
swathe no need to refer
„ Type 3 and above refer controversy
with tx type 3
„ Types 4 and above need surgery
„ Type 1 can lead to osteolysis of clavicle
„
AC Joint Repair
59
33
AC Joint Arthritis
•
•
•
•
•
Seen after AC separations
Pain with adduction of shoulder and
direct palpation
Osteolysis of distal clavicleclavicle- resorption
of distal clavicle
Rx Nsaids,
Nsaids, AC joint injection,
SurgicalSurgical- Distal clavicle excision
Osteolysis of Distal
Clavicle
60
34
Acute Musculotendinous
Injuries of the Shoulder
•
•
•
Rotator Cuff tears
Pectoralis tears
Biceps Tears
Pectoralis Tears
•
•
•
•
•
•
Resistive adduction eccentric exercises seen
wt. Lifters doing bench press
Anterior shoulder pain over pec musculature
Weakness with muscle deformity and
ecchymosis
MRI to delineate if tear is in tendinous area
which should be repaired in active athlete
Refer athletes who want to continue lift
heavy weights and for Cosmesis
Up to 40% loss of Strength
61
35
Ecchymosis Pectoralis Tear
Pec Major Tear
62
36
Biceps Tendon injuries of the
Shoulder
•
•
•
•
Rupture long head of BicepsBiceps- concentric and
eccentric muscle contracture
Assoc. with Rotator Cuff tears in patients over
40
Biceps acts as humeral head depressor and
resists anterior forces with the humeral head
ext rotated and abducted
SLAP tears Biceps anchor lesions on the
glenoid
Proximal biceps tear
Biceps
seroma
63
37
Distal Biceps Tear
Treatment Proximal Biceps
Tears
Tears manifest 2020-50% loss of
Supination and 10 % loss of Flexion
„ Throwing athletes and contact sport
athletes need tenodesis REFER
„ Most don’t need referral however follow
for chronic ache pain and some athletes
don’t like cosmetic look
„
Slap Tears
64
38
SLAP Tears of the Shoulder
•
•
•
•
•
Superior Labral tear Anterior to Posterior
seen in repetitive overhead activity
Disruption of Biceps anchor attachment on
the Glenoid
Four types of tear
Speed testtest- bicipital pain with resisted
forward elevation of arm while the elbow is
extended and the forearm supinated
O’Brien’s signsign- anterior shoulder pain with
the shoulder adducted and internally rotated
at 90 degrees flexion
Slap Test
Test
Active Compression
65
39
Compression Rotation Test
Treatment of SLAP tears
•
•
•
•
MRI with Contrast to delineate tear
Associated with GH joint instability esp.
ant/sup laxity
Arthroscopic repair vs. resection
treatment of choice
60% return to overhead sports
Normal Labral Insertion
66
40
Type 2 Labral tear
Slap Repair
Rotator Cuff Disease
•
•
•
•
Rotator cuffs four muscles important
depressors of humeral head
Initiate overhead movement by locking
humeral head in the glenoid
Spectrum of pathology tendinitistendinitissubacromial bursitisbursitis- full thickness tears
Loss of blood supply with ageage- 1/3 of patients
over 70yoa have rotator cuff tears
67
41
Rotator Cuff Pathology Etiology
Rotator Cuff Etiology
•
•
•
Impingement lesions assoc. with
subacromial spurs, loss of subacromial
space, Os Acromiale
Undersurface tears tensile overload
with loss of elasticity
Traumatic tears unusual in the young
population over age 40 associated
with shoulder dislocations
68
42
Impingement
test
69
43
Supraspinatus
test
Scapula Winging
70
44
Subscapularis Ruptures
•
•
•
•
MOIMOI- hyperextension/external rotation
Anterior shoulder pain with weakness
internal rotation
Lift off test with hand behind back push
away
MRI often needed to make diagnosis
Lift Off Test for
Subscapularis
Impingement Syndrome
•
•
•
•
•
•
Pain with forward flexion of shoulder usually
over 90 degrees
Subacromial arch pathology
Spectrum of disease age related 5th and 6th
decades highest incidence of RTC tear
presentation
NIGHT PAIN
Positive injection subacromial test
Younger age assoc. with GH instability
Importance of MRI with Contrast
71
45
Diagnostic Shoulder
Injection
Types of
Rotator
Cuff Tears
Bursal
side
Under
Surface
Full
Thickness
Types Of Acromion Anatomy
72
46
Type III Acromion
Ultrasound Rotator Cuff
Treatment of Rotator Cuff
Disease
•
•
•
•
Acute tears in young patient operate
within 6 weeks REFER
Non acute tears and Impingement
lesionslesions- Rehab to get back strength and
rom Failure to improve Refer
Nsaids,
Nsaids, ice, steroid injections
SurgicalSurgical- Intractable pain, loss of
strength, functional limitations
73
47
Rotator Cuff Arthropathy
Rotator Cuff Disease Chronic
74
48
Oslo
Fjord
75
49