Theory -Shoulder

Ortho Note

Symptoms

Pain

Weakness

Stiffness

Swelling

Deformity

Loss of Function

D/D FOR ABOVE SYMPTOMS IN SHOULDER

1) Referred Pain –

C. Spondylosis

                         Cardiac Ischaemia

2)Joint Disorders

                        Glenohumeral Arthritis

                        AC Joint Arthrits

                       

3) Bone Lesions

                        Infection

                        Tumors

4)Rotator Cuff Disorder

                        Tendinitis

                        Rupture

                        Forzen Shoulder

5)Instability

                        Joint Dislocation

                        Subluxation

                       

6)Nerve Injury

            Supraspinatus Nerve Entrapment

Signs

            Examination begins from the front and behind

Physical Examination

Look – Scars , sinuses , Not to miss examine the Axilla .

Shape

 asymmetry , wingling of scapula , wasting of deltoid, supraspinatus, Infraspinatus, AC Joint dislocation ,  Pop eye bulge

Position – Internally rotated arm

Feel

            Skin

            Bony Points

            Soft tissue

            Movement

                                    ( Observe from Front, Behind with either patient standing or sitting )

                                    Abduction –Glenohumeral 90 degrees,Scapulothoracic 60 degrees

                                    Flexion – 180 degrees

                                    Extension – 40 degrees

                                    Rotation-IR                                                     ER

            Always test passive movement after active movement

To test GH joint , anchor scapula, firmly press scapula from top of shoulder while moving shoulder with the hand .

Power – Deltoid , Serratus Anterior , Pectoralis Major , Rotator Power

Other tests

            Cspine, Ligament laxity , Neurological examination

Diagnostic Focus

Young Athelete

            Pain in elecation and ER

                                    Work towards rotator cuff lesion

                                    Inflammatory Arthritis

Elederly with long standing Pain and arthritis

                                    Woman – rotator cuff tears

                                               

           

Imaging

Xray – AP in plane of shoulder

           Axillary with Arm abduction

           Jt spacing narrowing , bone erosion , calcification in tendon

AC joint

           AP projection with cephalad tilt 20 degrees

Subacromial Space

           AP with 20 degrees Caudal

Arthrography

           Rotator cuff tear , some bankart lesion combined with CT/ MRI

CT

           Together with CECT , identify cuff tears and labral tears

USG

           Cuff tear , labral tears

MRI

           Rotator cuff tear- size , size of tear

                       Anatomy of coracoaromial arch and AC jt

           Instability

                       Associated with capsule, labrum,glenoid,humeral head,

                       Osteonecrosis of humeral head ,

                       Diagnosis and staging of tumor

MRA

           Sensitivity – 91 % , Specificity – 93 % for pathological labral tear

           More sensitive and specific for rotator cuff , partial undersurface tears

Shoulder MRI

Axial Stout

Axial T 1 gradient

Coronal Oblique T 1 , PD , T 2

Sagittal Oblique T 1 and T 2

Articular Cartilage – fluid like signals

Items to be evaluated

            Tendons

                        Suprspinatus , Infraspinatus,Subscapularis, Biceps

            Ligaments

                        Superior , Middle , Inferior  GHL

            Bursae

                        Subacromial , Subdeltoid, Subscapularis

           

Cornoal View

            Supraspinatus – underneath the AC Jt.

            Infraspinatus- Underneath the spine of scapula

            Subscapularis just below the acromion

            Biceps tendon covered by subscapularis

            Inferior Labrum and Sup Labrum

            Long head of biceps coursing over humeral head to base of labrum seen on MRA

Inferior GHL

U shaped , glenoid and humeral head attachment ligament and labrum low signal

Superior labrum – triangular , Inferior  Labrum – not triangular

To see labrum separately , MRA to be done

Synovial Inflammation or distended Inf GHL – Axillary pouch , looks clearly separate from inf labrum .

If Inf GHL is thick > 1 cm and v. ight - > Adhesive Capsulitis.

Below AC jt and Deltoid , Subacromial deltoid bursa

Axial Image

Middle GHL

Hill Sach’s Lesion

Biceps tendon

Labrum

            Sagittal

                        Coracoid , Acromion ,

                        Supraspinatus, Infraspinatus,Subscapularis,

                        Shape of acromion

                        Flat – 42 % , Curved – 39 % , Ant Hook – 11.5 % , Convex Underneath – 3 %

            AC Jt Arthritis

            Subcoracoid Bursitis

            Coracohumeral Lig

Shoulder Examination

ROM 

Flexion 180	Extension 180	Abduction 180	External Rotation 50
Internal Rotation 60

Rotator Cuff Strength

Subscapularis Strength	Lift Off test
Teres Minor	External Rotation against Resistance
Rotator Cuff strength	Abduction against resistance

Impingement Test

Job’s Empty Cane test
Hwakin’s Keneddy test

Acromioclavicular Joint Arthritis

Cross arm Adduction test

Instability Tests

Laxity

Sulcus Test

Apprehension

Instability of Shoulder

Shoulder                                  WIDE MOVEMENT

                                                COST OF STABILITY

Head in shallow socket by glenoid labrum ,glenohumeral ligaments, coracohumeral ligament , oberhanging coracoacromial arch and surrounding muscles .

Failure of these leads to Instability.

Common Terms

Laxity – Translation in glenohumeral joint, Physiological and Asymtomatic.

Instability – Abnromal symptomatic motion for that shoulder resulting in pain , subluxation or dislocation of shoulder.

Pathogenic Classification

Stanmore Instability Classification from Royal National Orthopaedic Hospital , London

            1)Strucutal Changes

                        Major trauma, disocation or recurrent microtraum

            2) Unbalanced muscle recruitment as opposed to muscle weakness

With time structural disorders are  associated with abnormal muscle pattern.

So intermediate problems also exist hence classified into 3 forms as in the diagram below .

                                    Polar Type I ,Traumatic Structural

                                                                        Less muscle Patterning

                                                Less trauma

            Polar Type III, Non structural                        Polar II Atraumatic ,Structural

Muscle patterning                  

Pathological Changes in each of Polar Types

Pathology	Group I	Group II	Group III
Trauma	Yes	No	No
Articular Cartilage damage	Yes	Yes	No
Capsular Problem	Bankart lesion	Dysfunctional	Dysfunctional
Laxity	Unilateral	Uni /Bilateral	Bilateral
Muscle Patterning	Normal	Normal	Abnormal

Traumatic Anterior Instability Polar Type I

Commonest instability : > 95 % cases

Acute Injury , Arm forced into Abduction , ER and Extension .

Recurrent dislocation cause

1)      Capsule and Labrum detach from anterior glenoid rim – classic bankart lesion        

2)      Hill-Sach lesion – indentation on posterolateral aspect of humeral head , compression fracture due to humeral head forced against anterior glenoid rim each time it dislocates.

3)      Recurrent Subluxation –alternates with dislocation

4)      Never dislocated – Inferior glenohumeral ligament stretched ,

Rotator cuff tear

                       

Clinical Features

Young patient

History of shoulder coming out , applied force in Abdction ,External roation and  Extension

Diagnosis verified by X-RAY ,

Tr – CR + Immoilization in a sling for several weeks.

Complications / Counselling

 Recurrent dislocation – 20 % in older people , 48 % overall.

Instability following acute dislocation – 88 % , 95 % in patients < 20 years

Dead arm Syndrom - Recurrent Subluxation , a less obvious symptom but causes catching sensation , followed by numbness or weakness while throwing a ball or swimming

Osteoarthritis

Investigations

            Shoulder AP with Int Rotation – Hill Sach’s lesion

            Axillary view – to see subluxation

            Stryker Notch View ?

            West point view  ?

-          To see bankart lesion

-          To see Hill Sach’s

            MRI or MRA – To see bony lesions and labral tears

            Arthroscopy – needed  to define labral tear

            Examination under Anaesthesia (EUA)

Determines direction of instability , important part of assessment , testing bilateral gives  sensitivity 100 % , specificity – 95 %

            Treatment

                                    If dislocation occurs at long intervals – avoid vulnerable positions.

                       

                                    Operation

                                                Frequent Dislocation especially if this is painful.

Recurrent Subluxation or apprehensive to participate in ADLs including support

Athelets – even in first dislocation

Types of Operation

1) Anatomical

            Repair Glenoid , Labrum aka Bankart Repair

2) Non-Anatomical

            Counteract pathological tendency to joint displacement

a)      Putti-Platt Procedure – shorten anterior capsule and subscapularis by an overlapping repair

b)     Latarjet Procedure – Re-inforce antero – inferior capsule by redirecting other muscles across front of joint , Coracoid process transfer for Bankart lesion 

c)       Eden Hybinette - Iliac crest transfer 

d)      Magnuson

e) Bristow - Glenoid Osteotomy


f ) Arthroscopy

                                               

           

                 

Gout

Olecranon bursa ,favorite site for gout ,

Acute gouty Olecranon bursistis presents with acute inflammatory signs with tender warm red swelling in posterior elbow above olecranon. Easily mistaken for Cellulitis or joint infection.

Diagnosis – Aspirate contains negatively birefringent monosodium urate crystals under polarized light .

Serum Uric Acid level may be elevated .

Treatment

 High dosage Anti-inflammatory Medical Prepearation

 Uric Acid Lowering drugs 

 Xanthine Oxidase Inhibitors 

Chronic Calcium Pyrophosphate Arthropathy (Pseudogout )

Suspected when OA occurs in unusual sites such as   elbow ,

X-ray Chondrocalcinosis and peri-articular calcification

Diagnosis – Typically +tively birefringent crystals in fluid aspirated from joint

Treatment – as for OA .