Disclosure. Traumatic Anterior Shoulder Instability 7/23/2018. Orthopaedics for the Primary Care Practitioner & Rehabilitation Therapist

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Ariel Goodwin
5 years ago
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1 Orthopaedics for the Primary Care Practitioner & Rehabilitation Therapist Christopher E. Baker M.D. Sports Medicine Shoulder Reconstruction Traumatic Anterior Shoulder Instability Disclosure Speaking/Consulting Fees ZimmerBiomet Smith & Nephew Sonosite No Conflicts Regarding this talk 1

Goals and Objectives Review Relevant Anatomy

2 Goals and Objectives Review Relevant Anatomy of Shoulder Initial History and Physical Radiographic Eval Reduction Techniques Controversies Surgical Considerations Shoulder Anatomy Shoulder most often dislocated joint- 24/100k, 10-20/50-60 Largest ROM Very little bony constraint Entirely reliant on soft tissues for stability Shoulder Anatomy Static Stabilizers 2

3 Shoulder Anatomy Dynamic Stabilizers Shoulder Anatomy Define Our Terms HPI Traumatic (96%) vs Atraumatic (MDI) First time vs recurrent Direction Age Activity 3

Mechanism of Injury: Anterior Dislocation Fall onto out stretched

$RTC tear or 15% GT fracture (>40 y/o 54% RTC tear) 15% neurologic$ injury (most commonly axillary nerve) Bankart lesion (85%-97% of

Lesion (40-90% of traumatic injuries) Provencher JAAOS 2012 ABCs

4 Mechanism of Injury: Anterior Dislocation Fall onto out stretched hand with an abducted and externally rotated upper extremity Physical Exam Concomitant injuries 60% (Atef Int Orthop 2016) 30% RTC tear or 15% GT fracture (>40 y/o 54% RTC tear) 15% neurologic injury (most commonly axillary nerve) Bankart lesion (85%-97% of traumatic injuries) Rowe JBJS 1978, Arciero AJSM 1997 Hillsachs Lesion (40-90% of traumatic injuries) Provencher JAAOS 2012 ABCs Physical Exam Inspection Palpation Sensory ROM Strength Stabilility 4

5 Inspection Palpation/Sensation Scapula Acromion, Spine Clavicle Humeral Shaft Physical Exam Inspection Palpation Sensory ROM Strength Stablility 5

6 Management Depends on setting On field - Acute reduction without radiographs ER/Office - Radiographic evaluation then reduction Radiographic Eval Standard Xrays- AP- Int/Ext, Scapular-Y, Axillary Lateral Special Xrays- True AP (45 deg), West Point/Apical Oblique (ant/inf glenoid), Stryker notch (Hill-Sachs) Importance of axillary lateral 6

$neurovascular structures After appropriate H&P Primary dislocation vs recurrent Little concern for fracture$ Appropriate post reduction follow-up Anesthesia Considerations Field of play In office or ER (Miller JBJS 2002)

Appropriate post reduction follow-up Anesthesia Considerations Field of play In office or ER (Miller JBJS 2002)

more cost Reduction Techniques Greater than a dozen reduction techniques in the literature Most are successful

7 Acute Reduction Field of Play Easier early prior to muscle spasm, no anesthesia required, less risk to neurovascular structures After appropriate H&P Primary dislocation vs recurrent Little concern for fracture Appropriate post reduction follow-up Anesthesia Considerations Field of play In office or ER (Miller JBJS 2002) Intra-articular injection Same degree of comfort Same success rate Sedation Higher complications Longer times and more cost Reduction Techniques Greater than a dozen reduction techniques in the literature Most are successful Equipment and help available Your comfort level/experience Commonly a combination of techniques Slow steady movements and traction 7

8 Hippocratic Foot in axilla Traction with IR and ER oscillations Kocher Matsen/Traction- Countertraction Sheet around axilla Traction around 45 Gentle ER 8

Chair Patient sits with arm over back of chair Physician

determines force Stimson Prone on stretcher Weight applied

reduces Scapular Manipulation Prone on stretcher arm hanging

9 Chair Patient sits with arm over back of chair Physician holds arm as patient stands/physician pulls Patient determines force Stimson Prone on stretcher Weight applied to arm (5lbs then increase) As muscle spasm abates shoulder reduces Scapular Manipulation Prone on stretcher arm hanging as in Stimson Gentle traction Internal rotation of inferior scapular angle 9

Spaso Supine on bed medial scapula stabilized

shoulder Arm is forward flexed with gentle

10 Spaso Supine on bed medial scapula stabilized by bed and physicians hand on anterior shoulder Arm is forward flexed with gentle traction Spontaneous reduction after a few minutes around 90 with ER FARES FAst, REliable, Safe Supine Gentle axial traction without counter traction Short vertical oscillating motion as arm is abducted ER at 90 and reduction around 120 FARES 10

Best Technique No definitive study comparing all techniques

painful Sayegh JBJS Am. 2009; 91:2775 82.

$Post-reduction xrays (eval for reduction and possible fracture)$ Delayed PT Return to Sport Surgery External Rotation Bracing ER

JBJS 2001 ER bracing resulted in less instability 26% vs 42%

11 Best Technique No definitive study comparing all techniques FARES vs (Hippocratic, Kocher, ER) FARES- faster, cheaper, less painful Sayegh JBJS Am. 2009; 91: Post-reduction Management Sling immobilization (swathe) Post-reduction xrays (eval for reduction and possible fracture) Controversies Immobilization in External Rotation Early vs Delayed PT Return to Sport Surgery External Rotation Bracing ER better approximated labrum on glenoid than IR Itoi MRI study JBJS 2001 ER bracing resulted in less instability 26% vs 42% Itoi JBJS 2007 RCT comparing ER to IR 30% vs 24% recurrence, no difference in dislocation rates Liavaag JBJS

Immobilization vs Early PT Early immediate

no difference in redislocation rates at 2

Return to Sport Multiple studies support that

<25 y/o 92% military Wheeler Arthroscopy 1989

bracing no evidence of reducing incidence of

12 Immobilization vs Early PT Early immediate ROM as tolerated vs 3-4 weeks immobilization, no difference in redislocation rates at 2 years Hovelius JBJS 1983 Pain, scapula, ROM Return to Sport Multiple studies support that recurrence rate very high in contact athletes <25 y/o 92% military Wheeler Arthroscopy % y/o Robinson JBJS 2006 Abduction bracing no evidence of reducing incidence of dislocation Operative vs Nonoperative Owens JAAOS

13 Advanced Imaging No consensus, patient specific Older patient higher risk of cuff tear Pain at 3-4 weeks Recurrent instability MRI eval Cuff, labrum CT to eval extent of bone loss Surgical Options Scope Bankart +/- Remplissage Open Laterjet Other allo/autograft (iliac crest, distal clavicle, tibial plafond) Reverse Arthroplasty Thank You! 13

This presentation is the intellectual property of the author. Contact them at for permission to reprint and/or distribute.

This presentation is the intellectual property of the author. Contact them at for permission to reprint and/or distribute. January 19, 2012 John W. Hinchey, MD Dept of Orthopaedic Surgery Shoulder & Elbow Service This live activity is designated for a maximum of 1 AMA PRA Category 1 Credit tm. Physicians should claim only