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Shoulder Problems

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

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  1. Shoulder Problems Fractures Instability Impingement Miscellaneous

  2. Anatomy • Bones • Joints / Ligaments • Muscles • Neurovascular

  3. Anatomy

  4. Anatomy Supraspinatus Anterior Posterior

  5. Anatomy

  6. Neurovascular Anatomy

  7. Anatomy:Joints • Acromioclavicular • Glenohumeral • Sternoclavicular • “Scapulothoracic”

  8. Shoulder problems : History • Onset,duration,location • ??trauma • radiation of pain • ?C-spine problems • instability,”dead arm” • repetitive use

  9. Physical Examination • deformity eg AC sep’n • ROM passive & active • Impingement tests • Instability tests • neurovascular exam

  10. Shoulder Problems

  11. Trauma !!

  12. Fractures • Clavicle • Proximal Humerus • Scapula / Glenoid

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

  14. CLAVICLE FRACTURE

  15. Clavicle Fractures : Figure 8 bandage

  16. Proximal Humerus Fractures • Neer- 4 parts • Vascularity of articular fragment • Displacement > 1 cm • Angulation > 45 degrees • Xray vs. CT scan • Interobserver variability

  17. Fractures : The Four Parts

  18. Fractures

  19. Proximal Humerus FracturesTreatment • Undisplaced & 2-part : Sling • 3- part : ORIF • 4- part : Prosthesis

  20. 4 PART FRACTURE

  21. NEER PROSTHESIS

  22. 3 PART FRACTURE

  23. ORIF 3 PART

  24. Fractures :Scapula / Glenoid • Rare • Most treated conservatively • Intraarticular displacement may need ORIF

  25. Shoulder Instability • Traumatic vs. Habitual • Unidirectional vs. Multidirectional • Unilateral vs. Bilateral

  26. Anterior Shoulder Instabliity • Hx of significant trauma • Very Painful • Most common • Nerve injury esp. axillary • Xray : Hill-Sachs defect

  27. The “Y” lateral Xray

  28. The “Y” lateral Xray

  29. Bankart and Hill-Sach’s lesions

  30. 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

  31. Anterior dislocation ;reduction

  32. Anterior Shoulder Instability • Surgery involves repair of torn anterior structures • Bankart lesion • High success rate with several different procedures

  33. Anterior Shoulder Instability • Traumatic • Unidirectional • Bankart • Surgery

  34. Multidirectional Instability • anterior,posterior,inferior • voluntary • atraumatic • ligament laxity • some are assoc’d with psychological problems

  35. Multidirectional Instability • Atraumatic • Multidirectional • Bilateral • Rehabilitation • Inferior Capsular Shift (RARELY)

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

  37. The Clavicular Ligaments

  38. Acromioclavicular Ligaments

  39. Inflammation:Calcific Tendonitis • Acute occ. severe pain • Mimics infection • Marked decrease ROM • Xray : Fluffy density near greater tuberosity • NSAIDS

  40. Calcific Tendonitis

  41. Inflammation • Septic • Gout • RA flare-up

  42. Shoulder Pain : Chronic

  43. Impingement Syndromes • Subacromial bursitis • Rotator cuff tendonitis • Bicipital tendonitis • AC arthritis • Rotator cuff tear

  44. Impnigement : Anatomy

  45. Acromion Morphology

  46. Impingement : Supraspinatus

  47. Impingement :Hx & Px • Repetitive overhead use of arm • Swimmers,pitchers • painful arc • impingement signs • decreased ROM active vs. passive • pain with resisted motion

  48. Impingement : treatment • Avoidance of offending activity • Physiotherapy • NSAIDS • Corticosteroid injection • Surgery : Subacromial decompression

  49. Impingement : Imaging • Xrays : often normal • Xrays : shape of acromion • Arthrogram • MRI • MSK Ultrasound

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