Shoulder injuries: Early surgery or not? Prof. Lars Engebretsen, Head of Scientific Activities
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1 Shoulder injuries: Early surgery or not? Prof. Lars Engebretsen, Head of Scientific Activities
2 Sport shoulder injuries that may need ACUTE surgery some clavicle, and displaced intraarticular fractures a-c joint grade 4-6, s-c joint with posterior dislocation very few shoulder dislocations some pectoralis major ruptures some cuff ruptures i.e subscap tendon rupture
3 Provencher at Steadman Clinic in Colorado Acute shoulder surgery: 1. High grade AC (type 5). Usually with 2 weeks. 2. acute RCT usually within 2 weeks. 3. Pec tear. 4. Subscap tear, especialy for rotator cuff. Younger patients may have a lesser tuberosity fracture that will be associated with subscap fracture. 5. SC dislocation management posterior especially. Anterior can wait. 6. Dislocation of shoulder with glenoid fracture (anterior usually) glenoid. 7. RC tear equivalent but a fracture from greater tuberosity. 8. long head biceps rupture with resultant popeye deformity and also weakness/pain. Repair using tenodesis technique 3
4 Sport shoulder injuries that should not have ACUTE surgery: most clavicle, and non displaced intraarticular fractures a-c joint grade 1-3, s-c joint without posterior dislocation The majority shoulder dislocations pectoralis major ruptures in older patients most cuff ruptures except for i.e subscap tendon rupture
5 High energy proximale humeral fracture Illustrated on this example Caroline 25 (with pat consent) Proff Roadracer i USA. High rating. Caroline injured shoulder i mass crash Roadracing-profilen crashed at Road America i Wisconsin Ortopedisk avdeling. 11/ 2015
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7 Conservative treatment of most proxinmal humeral fractures AO / OTA klassifikasjonen 1990 / 2007 Type A Extra articular 2 part Type B Extra articular 3+ fragments Type C Intra artikluær Ortopedisk avdeling. T. Fjalestad 1/ /10
8 Clavicle fractures
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11 Medial - 2-3% Midshaft 69-81% Lateral 21-28% Kahn JBJSA 2009
12 Dislocating forces
13 Non op treatment: Sling vs fig-o-8 The risk of axillary pressure sores, compression of the neurovascular bundle, Nonunion are higher in patients treated with the figure-of-eight Figure-of-eight bandage 9/34 (26%) dissatisfied Sling 2/27 (7%) dissatisfied Andersen Acta 1987
14 Long time results Have you recovered fully from your clavicular injury? 10 years after Not recovered fully 46% Pain at rest (VAS>=1) 9% Pain with activity (VAS>=3) 29% Unsatisfactory cosmetics (VAS>=3) 27% Nowak Thesis 2004
15 Surgery or not: For surgery Skin threatening Nerve and vascular injury Multitraume Opn fracture Against surgery Tendency to fall Drug misuse Neurologic disease Diabetes Low ADL NO bony contact Large shortening Z-fragment
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20 Sport shoulder injuries that may need ACUTE surgery a-c joint grade 4-6, s-c joint with posterior dislocation
21 a-c joint pathology: cross body adduksjon smerte
22 Anatomy - ligaments
23 12/11/201 XXX 24 7
24 Sport shoulder injuries that may need ACUTE surgery very few shoulder dislocations
25 Sport shoulder injuries that may need ACUTE surgery some pectoralis major ruptures
26 Clinical signs: muscle tear Long head of the biceps, observe the genarl cuff then pectoralis major-assymetri, axillary fold gone, deltoid rupture after open surgery
27 Sport shoulder injuries that may need ACUTE surgery some cuff ruptures i.e subscap tendon rupture
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30 Treatment of cuff ruptures: Early diagnosis and repair in young patients (MR needed) OBS Subscap! Non op and rehab in > 30 Shoulder dislocation that still has problems after a few weeks have rc tears!!
31 Decisions for Surgery Large Acute Tears Failure of conservative treatment
32 Sport shoulder injuries that may need ACUTE surgery Very few nerve injuries Major trauma w plexus Axillary nerve Suprascapular nerve
33 Scapula alata n thoracicus longus
34 N. suprascapularis
35 Sport shoulder injuries that should not have ACUTE surgery: most clavicle, and non displaced intraarticular fractures a-c joint grade 1-3, s-c joint without posterior dislocation The majority shoulder dislocations pectoralis major ruptures in older patients most cuff ruptures except for i.e subscap tendon rupture
36 Sport shoulder injuries that may need ACUTE surgery some clavicle, and displaced intraarticular fractures a-c joint grade 4-6, s-c joint with posterior dislocation very few shoulder dislocations some pectoralis major ruptures cuff ruptures i.e subscap tendon rupture
37 The Oslo Sports Trauma Research Center has been established at the Norwegian School of Sport Sciences through generous grants from the Royal Norwegian Ministry of Culture, the South-Eastern Norway Regional Health Authority, the International Olympic Committee, the Norwegian Olympic Committee & Confederation of Sport, and Norsk Tipping AS
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