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Anatomy, diagnosis and classification of sports injuries in the shoulder

Anatomy, diagnosis and classification of sports injuries in the shoulder. Mr. Nnamdi Obi Specialist registrar United Kingdom. Objectives. Review anatomy of the shoulder Review history and examination Acute traumatic shoulder instability. Introduction. Instability Glenohumeral dislocation

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Anatomy, diagnosis and classification of sports injuries in the shoulder

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  1. Anatomy, diagnosis and classification of sports injuries in the shoulder Mr. Nnamdi Obi Specialist registrar United Kingdom

  2. Objectives • Review anatomy of the shoulder • Review history and examination • Acute traumatic shoulder instability

  3. Introduction • Instability • Glenohumeral dislocation • SLAP tears • ACJ dislocation

  4. 30 YO male,Professional Rugby payer, first episode

  5. Anatomy • Synovial ball and socket joint • Articular surface covered with hyaline cartilage • Glenoid cavity deepened by labrum • Articulations

  6. Rotator cuff • Supraspinatus • Infraspinatus • Teres Minor • Subscapularis

  7. Ligaments • Glenohumeral • Superior Glenohumeral ligament • Middle Glenohumeral Ligament • Inferior Glenohumeral Ligament • Shoulder girdle • Coracoclavicular • ACJ proper • Acromioclavicular

  8. Biomechanics Static restraints Dynamic restraints Rotator cuff muscles Biceps tendon Scapular stabilizers Neuromuscular factors • Glenoid labrum • Articular version + conformity • Glenohumeral ligaments • Negative intra-articular pressure

  9. History(Acute traumatic instability) • Age • Mechanism • Traumatic • Atraumatic • Chronicity • Ease of dislocation • Expectations • Return to play

  10. Examination • Acutely • Pain limits most • Pre and post axillary nerve function • Sensory • Motor • Delayed • Hyperlaxity – predisposing • Provocative tests • Labral pathology (SLAP tear)

  11. Sulcus sign

  12. Apprehension

  13. Relocation test

  14. Labrum (SLAP) • O’Brien’s

  15. Labrum • Load & Shift

  16. Special investigations • Bones • Glenoid • Head humerus • Soft tissues • Rotator cuff • Labrum Ultrasound – no labrum MRI X Ray CT scan CT arthrogram MRI arthrogram

  17. Lateral radiographs • Posterior oblique scapular projection (“Neerlateral”, Neer 1970) • Produces considerable image overlap • Transthoracic (Vastamakiand Solonen1980) • Image overlap • Axial (Warrick 1965) • Requires shoulder abduction • Modified axial (Rockwood 1984) • Some shoulder abduction • Velpeau lateral (Wallace and Hellier 1983) • Patient needs to sit up • Apical oblique (Garth, Slappey and Ochs 1984)

  18. This is posterior dislocation But outlines glenoid and humeral head J Bone Joint Surg [Br] l988;70-B:457-60.

  19. Axial view Small Hills sachs Anterior glenoid Fine Almost normal AP Same patient Apical oblique Large Hills sachs Blunting anterior glenoid

  20. Bone loss - Plain x-ray - CT - CT recon

  21. 30 YO male, football, first episode

  22. Treatment How long ?

  23. MRI study • IR Labrum off glenoid • ER tension rests on glenoid • Randomized 40 pts • Sling IR Vs ER • Recurrence • IR 6/20, 30% • ER 0/20 J Shoulder Elbow Surg 2003;12: 413-15

  24. JBJS – B VOL. 91-B, No. 7, JULY 2009

  25. Premise • Younger = recurrent instability = immobilize longer • Older = stiffness = mobilize sooner • No benefit to immobilization in internal rotation > 1 week in pts under 30 yrs of age • Age of less than thirty years at time of injury predicts increased recurrence. • Best available evidence does show a clinical benefit to treatment in external rotation over conventional sling immobilization, but this advantage did not reach significance • BUT most ITOI J Bone Joint Surg Am. 2010;92:2924-33

  26. Take Home • Reduce • Sling comfort • Discard in 1 week • Physiotherapy, strengthen dynamic stabilizers • Under 30 years, continue contact sport • Counsel recurrence rate • Consider surgery following first dislocation

  27. SLAP Lesions • May be associated with dislocation but commonly due to pull on the arm, weightlifting, throwing, tackling • Symptoms – clicking, pain with overhead activities • Clinically – pain with eccentric biceps loading (e.g. going down on bench press)

  28. SLAP lesion classification

  29. Acromioclavicular joint (ACJ) injuries • Usually injured by a direct fall onto the point of the shoulder • Scapular forced downwards • Clinically, lateral end of clavicle prominent

  30. 30 YO rugby player again

  31. Classification of ACJ Injuries (Rockwood)

  32. Treatment • Non Operative • Grade 1-3 • Operative • Grade 4-6

  33. Conclusions • Acute instability common in athletes • Glenohumeral • ACJ • High level of function • Early return to play • Axillary or modified axillary view • Apical oblique

  34. References • Websites: • https://www.shoulderdoc.co.uk • https://www.orthobullets.com

  35. The End Email: njco@hotmail.com

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