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Shoulder Problems. Fractures Instability Impingement Miscellaneous. Anatomy. Bones Joints / Ligaments Muscles Neurovascular. Anatomy. Anatomy. Supraspinatus. Anterior. Posterior. Anatomy. Neurovascular Anatomy. Anatomy:Joints. Acromioclavicular Glenohumeral Sternoclavicular
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Shoulder Problems Fractures Instability Impingement Miscellaneous
Anatomy • Bones • Joints / Ligaments • Muscles • Neurovascular
Anatomy Supraspinatus Anterior Posterior
Anatomy:Joints • Acromioclavicular • Glenohumeral • Sternoclavicular • “Scapulothoracic”
Shoulder problems : History • Onset,duration,location • ??trauma • radiation of pain • ?C-spine problems • instability,”dead arm” • repetitive use
Physical Examination • deformity eg AC sep’n • ROM passive & active • Impingement tests • Instability tests • neurovascular exam
Fractures • Clavicle • Proximal Humerus • Scapula / Glenoid
Clavicle Fractures • Common • Most heal uneventfully • Figure of 8 x 6 weeks • Beware of high energy ie MVA • Assoc ‘d soft tissue
Proximal Humerus Fractures • Neer- 4 parts • Vascularity of articular fragment • Displacement > 1 cm • Angulation > 45 degrees • Xray vs. CT scan • Interobserver variability
Proximal Humerus FracturesTreatment • Undisplaced & 2-part : Sling • 3- part : ORIF • 4- part : Prosthesis
Fractures :Scapula / Glenoid • Rare • Most treated conservatively • Intraarticular displacement may need ORIF
Shoulder Instability • Traumatic vs. Habitual • Unidirectional vs. Multidirectional • Unilateral vs. Bilateral
Anterior Shoulder Instabliity • Hx of significant trauma • Very Painful • Most common • Nerve injury esp. axillary • Xray : Hill-Sachs defect
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
Anterior Shoulder Instability • Surgery involves repair of torn anterior structures • Bankart lesion • High success rate with several different procedures
Anterior Shoulder Instability • Traumatic • Unidirectional • Bankart • Surgery
Multidirectional Instability • anterior,posterior,inferior • voluntary • atraumatic • ligament laxity • some are assoc’d with psychological problems
Multidirectional Instability • Atraumatic • Multidirectional • Bilateral • Rehabilitation • Inferior Capsular Shift (RARELY)
Acromioclavicular Separations • Hockey , bikes • Coracoclavicular & Acromioclavicular ligaments • Grade 1-6 • Most treated conservatively • Late excision of outer end of clavicle
Inflammation:Calcific Tendonitis • Acute occ. severe pain • Mimics infection • Marked decrease ROM • Xray : Fluffy density near greater tuberosity • NSAIDS
Inflammation • Septic • Gout • RA flare-up
Impingement Syndromes • Subacromial bursitis • Rotator cuff tendonitis • Bicipital tendonitis • AC arthritis • Rotator cuff tear
Impingement :Hx & Px • Repetitive overhead use of arm • Swimmers,pitchers • painful arc • impingement signs • decreased ROM active vs. passive • pain with resisted motion
Impingement : treatment • Avoidance of offending activity • Physiotherapy • NSAIDS • Corticosteroid injection • Surgery : Subacromial decompression
Impingement : Imaging • Xrays : often normal • Xrays : shape of acromion • Arthrogram • MRI • MSK Ultrasound