5/19/2016 - PDF Document

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  1. 5/19/2016 The SHOULDER Ryan Dobbs, MD Reno Orthopaedic Clinic 1 Introduction The “shoulder” consists of 3 joints and one articulation Scapulothoracic articulation Sternoclavicular joint Acromioclavicular joint Glenohumeral joint Most mobile joint in body 2 2 Scapulothoracic articulation Snapping medial scapula Diagnosis elusive Rare, but treatable Crepitation - Painless or Painful Poorly understood Treatments unpredictable 3 3 Sternoclavicular Joint Posterior dislocation is dangerous Anterior dislocation is benign Degeneration can cause pain Resection is RISKY – undertaken with great caution and only when conservative measures exhausted 4 4 Acromioclavicular Joint Anatomy Clavicle Acromion Coracoid 5 5 Glenohumeral Joint Anatomy Humeral head Glenoid Labrum Capsule and ligaments Rotator cuff Proximal biceps tendon 6 6 Shoulder Anatomy 7 7 Bony Anatomy 8 8 Glenohumeral Joint Labrum 9 9 1

  2. 5/19/2016 7 8 Glenohumeral Joint Labrum Acute, unidirectional anterior or posterior instability Multi-directional instability Superior labral tears Rotator Cuff Impingement Acute tears Throwers Dislocation Chronic tears Etiology Articular cartilage Avascular necrosis Glenohumeral arthrosis Rotator cuff arthropathy 9 9 Labrum 10 10 Muscles of the Rotator Cuff 11 11 Muscles of the Rotator Cuff 12 12 Rotator Cuff 13 13 Subscapularis 14 14 Supraspinatus 15 15 Supraspinatus muscle 16 16 Infraspinatus 17 17 Teres Minor 18 18 History “Tell me about your shoulder.” Initiation of problem Trauma Modifiers Aggravation Alleviation Activity Position Mechanical symptoms Night pain   19 19 Differential Diagnosis for “shoulder pain” Shoulder pain 20 20 2

  3. 5/19/2016 Differential Diagnosis for “shoulder pain” Shoulder pain Typically Anterior Rotator cuff pain refers to deltoid insertion Cubital tunnel syndrome common Cervical Spine Posterior Distal neurologic involvement Scapula Posterior Activity related Cardiovascular system 20 20 Physical Examination Inspection Scapular winging Infraspinatus wasting AC joint deformity Muscular symmetry Palpation Tenderness Percussion Tinel’s Ausculation Crepitance  21 21 Physical Examination C-spine ROM Impingement Tenderness Sensation Strength Special tests Imaging X-ray (Grashe, AP, axillary, outlet) MRI (open-air, 1.5T, 3T, arthrogram) 22 22 Physical Exam - ROM Active and Passive Forward flexion Abduction External Rotation Internal Rotation 23 23 24 25 26 3

  4. 5/19/2016 Internal Rotation Physical Exam - Strength 24 24 Physical Examination - Strength 25 25 Special Tests Impingement Neer Hawkins Cross-body adduction Labrum/Biceps O’Brien’s Speed’s Yergason’s Instability A/P drawer Apprehension/Reduction Sulcus Generalized laxity signs Jerk sign 26 26 Physical Examination Special Tests - Impingment 27 27 Physical Examination Special Tests - AC joint 28 28 Physical Examination Special Tests - SLAP tear 29 29 Physical Examination Special Tests - Biceps 30 30 Physical Examination Special Tests - Biceps 31 31 Physical Exam Special Tests - Instability 32 32 Physical Examination Special Tests - Instability 33 33 Physical Examination Special Tests - Instability 34 34 X-rays 35 35 MRI Injection vs. MRI? MRI first if ANY doubt about RC integrity  Open vs. Closed MRI? 36 36 4

  5. 5/19/2016 36  Open vs. Closed MRI? Open only when absolutely no other choice (>400#)  Non-contrast MRI vs. MRI arthrogram? Plain MRI to r/o RCT Arthrogram for questions of instability or SLAP tear rarely needed for > 40 yo increases rate of rotator cuff tear false positives MRI Open MRI Advantages: Patient comfort Cost? Disadvantages: Poor image quality Closed tube MRI Advantages Improved image quality More scanners Disadvantages Claustrophobia 37 37 1 1 2 2 3 3 4 4 MRI Plain MRI Indications: Rotator cuff tears Over 40 years old Atraumatic Deltoid insertion pain    When in doubt, MRI without 38 38 1 1 2 2 3 4 4 3 MRI Arthrogram Indications: Labral tears Under 40 years old Traumatic History of dislocation    NO indication for IV contrast 39 40 5

  6. 5/19/2016  NO indication for IV contrast Common Shoulder Maladies 39 39 Common Maladies Glenohumeral Joint Instability, SLAP, adhesive capsulitis, DJD Subacromial Space Rotator cuff, Impingement, Calcific Tendinitis Acromioclavicular joint Separation, DJD Biceps Tendonitis, Instability, Tear Sternoclavicular Joint Separation, DJD 40 40 Common Maladies Instability  Glenohumeral Joint - Instability History: Traumatic onset Position of arm at time of injury Reduction required in ER? Or Spontaneous? Physical Exam Apprehension, Reduction Sulcus, generalized laxity signs Jerk sign - posterior 41 41 Common Maladies Instability Glenohumeral Joint – Instability X-rays Usually negative Hill-Sachs lesion, bony bankart MRI – ARTHROGRAM Labral tear, HAGL lesion Treatment - Age, activity level, concurrent pathology, recurrence CONCERNS: Younger patients = Recurrence Older patients = Rotator Cuff Tear or axillary nerve injury 42 42 Common Maladies SLAP tear Glenohumeral Joint - SLAP tear History Trauma (traction injury) vs. Insidious onset 43 43 6 44

  7. 5/19/2016 43 History Trauma (traction injury) vs. Insidious onset Age (traumatic vs. degenerative) Physical Examination O’Brien’s positive Common Maladies SLAP tear Glenohumeral Joint - SLAP tear X-rays - negative, often acromial or AC path in degenerative MRI - ARTHROGRAM (often inconclusive) Treatment: PT IA injection SLAP repair (young, acute) Biceps tenodesis and labral debridement (degenerative)   44 44 Common Maladies Adhesive Capsulitis Glenohumeral Joint - Adhesive Capsulitis History Painful ROM Usually minor - moderate trauma followed by immobilization Diabetes Physical Exam Limited active AND PASSIVE ROM (esp. IR)   45 45 Common Maladies Adhesive Capsulitis Glenohumeral Joint - Adhesive Capsulitis X-ray/MRI - non-diagnostic Treatment: PT NSAIDs IA injection Oral steroids MUA Arthoscopic LOA with A/P capsular releases (for recalcitrant cases > 1 year)   46 46 Common Maladies DJD 47 47 7

  8. 5/19/2016 Common Maladies DJD Glenohumeral Joint - Degenerative Joint Disease History Progressive loss of motion and pain “Tooth ache”, “Grinding” Night pain Physical Exam Limited ROM Crepitation with motion 47 47 Common Maladies DJD Glenohumeral Joint - Degenerative Joint Disease X-ray Diagnostic MRI Usually unecessary Can help differentiate the need for TSA vs. reverse TSA Treatment: NSAIDs IA injection (few) TSA Reverse TSA 48 48 Common Maladies Subacromial Impingement History Rare in < 40 yo Pain with overhead reaching, lifting, sports Positional pain Physical Examination Neer, Hawkins, Whipple - positive Normal PROM, RC strength 49 49 Common Maladies Subacromial Impingement X-ray Type 2/3 acromion very common AC joint often degenerative MRI - Tendinopathy Treatment PT/NSAIDs, Injections Arthoscopic subacromial decompression for failure of extensive conservative management (usu find concomitant pathology) 50 50 51 8

  9. 5/19/2016 (usu find concomitant pathology) Common Maladies Calcific Tendinitis History Impingement pain baseline Intermittent episodes of severe, incapacitating pain < 1 week Physical Examination Neer, Hawkins, Whipple – positive Painful ROM Possible adhesive capsulitis 51 51 Common Maladies Calcific Tendinitis X-rays - diagnostic MRI - often false negative Treatment Acute Injection NSAIDs +/- narcotics +/- oral steroids Chronic Injection, PT, NSAIDs Chronic > 1-2 years w/ multiple bouts of acute reactions = consider arthroscopic excision in dormant phase 52 52 Common Maladies Rotator Cuff Tear History Traumatic or insidious Pain localizing to deltoid insertion Pain with overhead reaching, lifting Night pain Physical Examination Pain > weakness with RC isolation Drop arm, lag signs with massive tears Belly press/lift off with subscapularis tears 53 53 Common Maladies Rotator Cuff Tear X-ray - Humeral head elevation (acute or chronic massive), acromial and humeral head sclerosis with chronic massive Treatment Partial (PT, injections, repair if > 50%) Full thickness < 5 cm retraction with minimal atrophy = repair Full thickness > 5 cm, chronic, atrophy = conservative vs. RTSA 54 54 55 9

  10. 5/19/2016 Full thickness > 5 cm, chronic, atrophy = conservative vs. RTSA Common Maladies AC separation History Direct blow to the shoulder Physical Examination TTP over AC joint Pain w/ CB adduction Deformity in all but grade I 55 55 Common Maladies AC separation X-rays Deformity in all but grade I Clavicle views best MRI - unnecessary Treatment Conservative for all but grade 5 initially Reconstruction an option for symptomatic grades 3-6 56 56 Common Maladies AC joint arthritis History Pain with lying on the shoulder, reaching across the body or behind the back Common in weight-lifters, laborers, elderly Physical Exam TTP over AC joint Pain with CB adduction 57 57 Common Maladies AC joint arthritis X-rays DJD on AP, axillary views MRI Increased T2 signal at AC joint Treatment PT, NSAIDs, injections Arthroscopic DCR 58 58 Common Maladies Biceps pathology History Pain referable to anterior shoulder/biceps muscle Worsened with supination Physical Examination Positive Speed’s, Yergason’s, O’Brien X-ray 59 59 60 10

  11. 5/19/2016 Positive Speed’s, Yergason’s, O’Brien X-ray Often acromial/AC joint pathology Common Maladies Biceps pathology MRI Good for splitting of biceps or instabilty Often difficult to evaluate intra-articular portion of biceps Arthogram for SLAP tears Treatment Eccentric strengthening in PT NSAIDs, Injection Biceps tenodesis 60 60 THANK YOU 61 61 11