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Anatomy And Injury around Shoulder Joint, Orthopaedics
- 1. Shoulder Joint Dr. Bipul Borthakur Professor And Head Department of orthopaedics Assam Medical College Dibrugarh, Assam
- 2. Basic shoulder anatomy Bony anatomy humerus • Scapula – 1. glenoid 2. acromion 3. coracoid 4. scapular body Clavicle Sternum
- 3. Joints Sterno clavicular joint Acromio clavicular joint Scapulo thoracic joint Gleno humeral joint
- 4. Glenohumeral Joint Commonly referred to as the shoulder joint Most common dislocated joint Lacks bony stability Composed of Fibrous capsule Ligaments Surrounding muscles Glenoid labrum
- 5. Rotator cuff muscles Supraspinatus - abduction Infraspinatus – external rotation Teres minor – external rotation Subscapularis – internal rotation
- 6. Big Muscles Deltoid Pectoralis major Trapezius Latissimus dorsi Teres major Biceps
- 7. Nerve supply Suprascapular nerve Axillary nerve Lateral pectoral nerve Blood Supply Anterior circumflex humeral artery Posterior circumflex humeral artery Suprascapular artery
- 8. Glenohumeral stability Static stabalizers 1) Labrum 2) Ligaments – 1. superior glenohumeral 2. middle glenohumeral 3. inferior glenohumeral 4. posterior glenohumeral Capsule 1) Bones ( to a certain extent ) • Dynamic stabalizers 1) rotator cuff muscles 2) Scapular muscles 3) Scapulo thoracic rhythm 4) And even the axial core muscle of the body
- 10. Shoulder Biomachanics Stability Ratio. Glenodiagram. Scapulohumeral Rhythm. Force couple Mechanism.
- 11. Examination of Shoulder Joint
- 12. Physical examination Inspection 1. Atrophy 2. Bulging 3. Deformity • Palpation • Range of motion • Tests and signs
- 13. Tests and signs Impengement sign – Positive in rotator cuff inflammation/tear the examiner stabilizes the scapula while standing behind the patient and passively internally rotate and forward flexes the patient shoulder more than 90 degree Impengement test – injection of local anesthesia(5ml of 1% lignocaine) in the subacromial space. It is positive if the pain goes away impingement sign
- 14. Special tests Modified Neer’test (Hawkins kennedy test Painfull arc test Jobe’s test
- 15. TEST FOR ROTATOR CUFF LESION DROP ARM TEST- Helpful in diagnosing massive rotator cuff tear the examiner abducts the patient shoulder to more than 90 degree and then ask the patient to hold it HORNBLOWER SIGN- To test the integrity of infraspinatus and teres minor tendon the patient elbow is flexed to 90 degree and then arm is elevated to 90 dergree of abduction. patient rotates the arm externally against examiners resistance
- 17. investigations Xray - 1. An ap view x-ray is enough in most cases 2. Lateral and axillary views for specific cases like posterior shoulder dislocation • usg- has been reported to detect full thickness tears in 92 to 95 % of cases • Ct scan – are helpful in assessing glenoid bone loss and humeral head in recurrent instabilities. • Mri/arthrography – for soft tissues injuries like rotator cuff tears • Arthtoscopy – it is used for treatment and diagnosis of most shoulder disorders these days • Sometimes nerve conduction studies and electromyography studies may be done
- 18. Scapular y view xray Diagnostic arthroscopy
- 20. ROTATOR CUFF Syndrome Caused by 5 conditions Supraspinatus tendinitis(impingement syndrome) Rotator cuff rupture Acute calcific tendinitis Biceps tendinitis and/or rupture Adhesive capsulitis (frozen shoulder)
- 21. IMPINGEMENT SYNDROME Age : over 40 years Overhead activities Bursitis and supraspinatus tendinitis Acromial shape:type 2 and 3 acromion AC arthritis or ac joint osteophytes may result in impingement and mechanical irritation to the ratator cuff tendons
- 22. SYMPTOMS Pain in flexed, internally rotated and overhead position. Pain from subacromial bursitis or rotator cuff tendinitis Pain when sleeping on the affected side Pain often worse at night Decreased range of motion especially abduction
- 23. Differential diagnosis Rotator cuff tear Calcific tendinitis Biceps tendinitis Cervical radiculopathy Acromioclavicular arthritis Glenohumaral instability Degeneration of glenohumeral joint
- 24. Physical Examination Atrophy of rotator cuff muscle Decreased range of motion (especially internal rotation and adduction) Weakness in flexion and external rotation Pain on resisted abduction and external rotation Pain on impingement tests(neers impingement test ,Hawkins impingement test)
- 25. Radiological finding plain x-ray . acromial spurs . Ac joint osteophytes . Subacromial sclerosis . greater tuberosity cyst mri . To confirm the diagnosis and rule out rotator cuff tear
- 26. • Management Conservative treatment Always start with it Operative Indicated when conservative measures fail
- 27. Conservative Treatment Avoid painful over head activities Physiotherapy 1. stretching and range of motion exercise 2. strengthening exercise NSAIDS Steroid injection into the subacromial space
- 28. Operative Treatment The goal of surgery is to remove the impingement and create more subacromial space for the rotator cuff Indicated if there is no improvement after 6 months of conservative treatment The anterolateral edge of the acromium is removed Success rate 70-90%
- 30. Causes of rotator cuff tear Intrinsic factors . vascular . Degenerative(age related) Extrinsic factors impingement .acromial spurs .ac joint osteophytes repetitive use Traumatic (example a fall or trying to catch or lift a heavy object)
- 31. Clinical presentation Shoulder pain (the most important) Anterior with radiation to arm When elevating the arm Progression: pain at rest, frozen shoulder Decreased ROM
- 32. Classification Rotator cuff tear can be classified according to 1. Depth 2. Etiology 3. Age of tear 4. Size 5. Number of tendon involved 6. Patte classification – most elaborate
- 33. Diagnosis History Physical examination test used in shoulder evaluation( drop arm test, hornblowler sign) X- rays MRI- best choice for diagnosis
- 34. Treatment of rotator cuff tear Conservative Conservative for (partial thickness) tears Training for strengthening core body and shoulder girdle musculature preventing tear progression (rest ,activity modification , gentle passive and active motion exercise ,anti-inflammatory medication , subacromial corticosteroid injection) Operative minimum of 2-3 months/for full thickness tear surgical repair can be performed through Open Arthroscopically assisted mini open, All- arthroscopic techniques
- 35. Adhesive capsulitis(frozen shoulder) Functional loss of passive and active shoulder motion More common among woman Age 40-60 year Patho anatomy . Inflammatory process causing fibroelastic ,proliferation of joint capsule leading to thickening, fibrosis, and adherence of joint capsule to itself and humerus .fibroblast/myofibroblast with abundant type 3 collagen .leads to mechanical block to motion
- 36. Frozen shoulder Associated with .diabetes mellitus .dupuytrens disease .hyperlipedemia .hyperthyroidism .cardiac disease .hemiplegia
- 37. Frozen shoulder Clinical feature Mainly pain and stiffness Four stages of adhesive capsulitis stage 1-(symptoms for <3 months) : mild to moderate dull aching pain even at rest progressive loss of motion loss of external rotation and abduction with mild decrease in internal rotation in adduction stage 2-(symptom for 3-9 months): continuum of stage 1 with more scarring and similar synovitis loss of motion is present in all planes and full ROM is painfull
- 38. Frozen shoulder Stage 3-(symptoms for 9-14 months): initial history of painful stiffness of shoulder that burns into relatively pain free but stiff shoulder Stage 4-(stage of thawing): characterized by the slow ,steady recovery shoulder function there is capsular remodelling with increased movements and shoulder usage
- 39. Treatment Depends on the stage of the disease Patient education in all phases Corticosteroid/long acting local anesthesia injection Manipulation of shoulder under anesthesia Arthroscopy(releases fibrotic capsule) Psychotherapy is suggested due to psychological underlying causes of the disease
- 40. Acute calcific tendinitis Acute shoulder pain following deposition of calcium hydroxyapatite Crystals in the supraspinatus tendon Clinical feature . age 30-40 . agonizing shoulder pain after exercise . Tender to palpitation . Subside within days spontaneously treatment .Rest in a sling .NSAIDS .corticosteroids local injection .surgery: calcific material scoped out
- 41. Rupture of long head of biceps Usually accompany rotator cuff disruption Usually seen in middle-aged patients Younger patients in heavy weightlifting or other high energy contact sports Snap in the shoulder after lifting an object Severe pain and swelling with feeling of loss of strength especially in elbow flexion and shoulder external rotation Popeye sign Treatment conservative surgical-tenodesis, Tenotomy
- 42. Dislocation of the shoulder Mostly anterior >95% of dislocation Posterior dislocation occurs 2-4% True inferior dislocation (luxation erecta) occurs <1% Habitual non traumatic dislocation may present as multi directional dislocation due to generalized ligamentous laxity and is painless
- 43. Mechanism of anterior shoulder dislocation Usually indirect fall on abducted and extended shoulder May be direct when there is a blow on the shoulder from behind
- 44. Clinical Picture Pain Holds the injured limb with other hand close to trunk The shoulder is abducted, and the elbow is kept flexed There is loss of the normal contour of the shoulder Anterior buldge of the head of humerus may be visible A gap can be palpated above the dislocated head of the humerus
- 45. Imaging Radiographs AP , Axillary , Scapular Y views must be taken findings . Incongruence between the humeral head and glenoid . the humeral head is displaced medially and overlies the glenoid . Anterior vs posterior location of the humeral head can be best visualized on the axillary lateral or scapular y view
- 46. Associated injuries of Anterior shoulder Injury to the neuro vascular bundle in axilla Injury to the axillary nerve (usually stretching leading to temporary neuropraxia) Associated fracture Rotator cuff tear-more likely in older patients
- 47. Associated condition • Bankart lesion . Fracture of the anterior inferior glenoid following impaction of the humeral against the glenoid Hill-sachs lesion . Compression chondral injury of the posterior superior humeral head following impaction against the glenoid
- 48. Management of Anterior Shoulder Dislocation It is an emergency It should be reduced in less than 24 hours or there may be avascular necrosis of head of humerus Following reduction, the shoulder should be immobilized strapped to the trunk for 3-4 weeks and rested in a collar and cuff.
- 49. Methods of reduction of anterior shoulder dislocation Hippocrates method Stimpson's technique Kochers technique
- 50. Posterior shoulder dislocation Posterior shoulder dislocation are less common than anterior shoulder dislocation Incidence 2-4% Risk factor .bony abnormality .Ligamentous laxity
- 51. Presentation History of trauma or micro trauma with arm in flexed, adducted , and internally rotated Chronic instability often present with insidious onset Symptoms pain with flexion , adduction , and internal rotation of arm Physical examination inspection- prominent posterior shoulder and coracoid for acute posterior dislocation may be normal from chronic posterior instability from micro trauma motion- limited external rotation for acute posterior dislocation shoulder locked in an internally rotated position common in undiagnosed posterior dislocation
- 52. Imaging Radiograph recommended views ap- may show a lightbulb sign axillary lateral-best view to demonstrate dislocation CT analyze the extent and location of bone loss in chronic dislocation (>2 to 3 weeks ) MRI indication- chronic posterior instability without history of acute posterior dislocation evaluate for suspected posterior labral tear ,reverse hill- sachs lesion, or associated rotator cuff tear
- 53. Treatment Non operative . acute reduction and immobilization in external rotation for (4 to 6 weeks) . physical therapy Operative .open or arthroscopic posterior labral repair .open or arthroscopic posterior capsular shift and rotator interval closure
- 54. Atraumatic osteolysis of the distal clavicle(idiopathic clavicle osteolysis, wrestler's syndrome) Etiology Traumatic Atraumatic( arises from repeated micro trauma) The condition is most common in athletes involved in weight training
- 55. Clinical Feature Painful, dull ache localized to the ac joint Pain worse at the beginning of exercise often radiating down into the deltoid and trapezius Abduction of the arm beyond 90 degree and throwing causes pain with disease progression, but the movements at glenohumeral joint are usually full
- 56. Differential Diagnosis Cervical spondylosis Rotator cuff disease Hyperparathyroidism Gout Scleroderma Infection Rheumatoid arthritis Multiple myeloma
- 57. Radiological Finding X ray- zanca view of clavicle ( cephalad tilt of the beam by 15 degree) Acromium is speared in the disease process while lesion is seen in the distal clavicle Mri- demonstrate bone marrow edema
- 58. Treatment Conservative Prohibiting the stressful exercise and weight training give relief in majority of patient Nsaids Ancillaries to conservative management include local heat, range of motion and stretching and strengthening exercise Surgical if conservative management failed Consist of resection of the distal clavicle( open or arthroscopically)
- 59. Osteoarthritis of shoulder joint Third most common joint affected by degenerative joint disease after knee and hip Clinical feature Age 50-70 Early features are similar to impingement syndrome Chronic dull pain located at the joint initially at extremes of motion gradually Restricting all movements On examination- patient have disuse atrophy
- 60. Differential diagnosis Adhesive capsulitis Inflammatory arthropathy Locked posterior dislocation
- 61. Radiology Radiographs – reveals typical osteophytes formation Wear of the joint Decreased joint spaces CT scan- may be done to assess eccentric wear of the joint prior to planning arthroplasty
- 62. Treatment Conservative Rest Activity modification Education Analgesic Surgery Total shoulder arthroplasty hemiarthroplasty
- 63. Suprascapular nerve syndrome Anatomy 1. Suprascapular nerve is a mixed nerve originating as a branch from upper trunk of brachial plexus(c5, c6) 2. It passes through the scapular notch beneath the superior transverse ligament 3. It supplies( supraspinatus muscle, coracohumeral, coracoacromial ligaments, the subacromial bursa and the acromioclavicular joint, infraspinatus, shoulder joint and scapula
- 64. Etiology Trauma – direct blow to erbs point, scapular fracture and malunion or hematoma from fall on outstretched hand Tractional damage Entrapment neuropathy of the scapular nerve
- 65. Clinical Presentation Low intensity pain Paresthesia Muscle atrophy Scapulohumeral rhythm is altered Combined sensory motor symptoms Investigation Radiologically-scapular notch view Mri- soft tissue cause of nerve compression Electromyography – usually confirms the diagnosis
- 66. Treatment Conservative 1. Exercise 2. Local steroid injection Surgical 3. If conservative management fail 4. It includes neurolysis and nerve decompression 5. Posterior(Swafford and litchman) approach
- 67. Hemorrhagic shoulder (Milwaukee shoulder) Recurrent effusions of the shoulder along with severely destroyed glenohumeral joint Aggregates of calcium hydroxyapatite crystals in the synovial fluid release of lysosomal enzymes (a)Collagenase (b)Neutral proteases from synoviocytes periarticular tissues, including the rotator cuff.
- 68. Epidemiology Elderly patient( 60-90 year) Female preponderance in the ratio of 4:1 Unilateral shoulder joint involvement is much more Risk factor 1. Female gender 2. Calcium pyrophosphate crystal deposition 3. Trauma 4. Overuse syndrome 5. Neuropathic joint 6. Dialysis associated arthropathy 7. Joint denervation 8. Advanced age
- 69. Clinical features Elderly with long history of shoulder pain Swelling and instable shoulder Crepitus Loss of active movement Multiple small dilated blood vessels that produces repeated subcutaneous hemorrhages
- 70. Radiology Radiographs –demonstrate joint space narrowing, advanced degenerative changes, loss of architecture of humeral head with flattening, osteophytes mixed subchondral sclerotic and cystic changes at the articular surface Ultrasonography-intra articular synovial proliferation and large effusions associated with rotator cuff tears
- 71. Differential Diagnosis Septic arthritis Tuberculosis of the shoulder joint Rapidly destructive arthropathy of unknown cause Neuropathic arthropathy Osteonecrosis Other crystal associated arthropathy
- 72. Treatment Supportive based primarily on physiotherapy but patients who fail to respond to same may be benefited in a limited extent by arthroplasty
- 73. Tuberculosis Of Shoulder Joint Incidence of 1-3% of skeletal tuberculosis Preponderance of males Left side is more often affected Head of humerus is prime target as destructive changes are maximally seen Two forms- 1. sicca form in adult 2. Fulminant form in children
- 74. Type 1(sicca form)- Seen in adult Present like osteoarthritis with degenerative changes Pain aggravated on movement Presence of Inflammatory symptoms for pain(aggravation in night in morning, cold intolerance, stiffness)
- 75. Type 2( caries exudata , wet form, fulminant form) Swelling and cold abscess Inflammatory changes in the synovial membrane is mroe marked Joint effusion ,inflammatory thickening of periarticular connective tissue
- 76. Clinical features Sicca form- Pain of insidious onset, more at night On examination- atrophy of the shoulder girdle muscle and prominent bony landmarks The moments are reduced in all direction and often painful Tenderness is initially present on posterior aspect that later becomes generalized
- 77. Clinical features Exudative form- Swelling with effusion Cold abscess The child is often malnourished and cachectic look
- 78. Radiology Radiographic finding Phemisters Triad periarticular osteoporosis peripherally located osseous erosion narrowing of the interosseous space In addition – subchondral erosion , reactive sclerosis, periosteal reaction in the sicca form In exudative form- periarticular osteophytes
- 79. Treatment Antitubercular treatment is the mainstay of treatment In late cases when shoulder arthrosis has developed – arthrodesis/arthroplasty
- 80. Thank You