Shoulder Case Studies
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1 Shoulder Case Studies Eden Raleigh Orthopaedic Surgeon Shoulder & Knee Surgery Ph:
2 My Background Specialising in Shoulder and Knee Surgery Main focus on Arthroscopic/Sports Surgery FRACS (2006) Melbourne Fellow Guy s & St. Thomas, London Fellow Paris Cinq (Paris) Fellow PanAm Clinic (Canada)
3 WHERE AM I? 89 Erin St, Richmond (op. Epworth) Bounce Healthcare Epworth Eastern Epworth - Lilydale Consulting Suites Berwick
4 Case 1 45 year old Man Presents with 2 weeks of impingement type symptoms in dominant shoulder Last few days of increasing pain and weakness
5 Signs Strength testing ie. empty can,
6 Signs Impingement tests ie. Neer and Hawkins- Kennedy
7 XR: mild ACJ OA MRI: Full thickness tear in S.S. - 2cm retraction What is the BEST way to tell if his weakness is related to tendon dysfunction or pain? A. MRI B. XR C. Injection with Local Anaesthetic & Reexamine D. CT Scan
8 Diagnostic Injection What is the BEST way to tell if his weakness is related to tendon dysfunction or pain? A. MRI X B. XR X C. Injection with Local Anaesthetic & Re-examine D. CT Scan X Strength testing after lignocaine injection may help to distinguish RC tendinopathy vs. tear
9 When to Refer? 1. Young < 60 yrs 2. Active/independent in older pop. 3. TRUE WEAKNESS with functional disturbance 4. Failure of non-operative therapy
10 Osteoarthritis Should I order an xray?? Bony metastasis these patients presented with rot cuff tears!!
11
12 CSI & Hydro CSI- Into subacromial space - Steroid/LA Hydrodilatation - Into Glenohumeral Joint ml good results What are you treating??
13 When is CSI the best option Impingement pain +- RCT For diagnostic reasons - is this patients pain due to impigment - Exclude ACJ, GHJ OA, Labral etc.
14 When are Hydro s a good idea Capsulitis Frozen Shoulder Stiffness Remember, most patients with Impingement/cuff stiffness have the pathology in the subacomial space, and wont respond to hydro. If you fix the subacromial space, you can get the shoulder going
15
16 Important points MRI overcall everything - don t get too caught up in distal clavicle osteolysis, ACJ OA, Degenerate SLAP tears Go on clinical findings
17 How Many Injections Can I give? How Often Can I give Injections? PRP? Stem Cells?
18 Rotator Cuff Arthropathy When a massive tear is present, the shoulder will sublux superiorly. Secondary arthritis will follow
19 Standard Shoulder Replacement?
20 Treatment? Repairing the cuff is not possible Surgical treatment is a reverse shoulder prosthesis or Hemi-Replacement
21 Case 2 18 year old - 3rd anterior dislocation dominant shoulder PS - Always take pre-reduction xrays (Avoids missings # s, confirms direction of dislocation )
22 What does this Xray Show? 1. Bankart lesion 2. Persistent anterior dislocation 3. Hills-Sachs lesion 4. Rotator cuff tear
23 What does this Xray Show? 1. Bankart lesion X 2. Persistent anterior dislocation X 3. Hills-Sachs lesion 4. Rotator cuff tear X
24 BANKART - Antero-inferior labral tear
25 What We Do
26 Patient Questions 1) Chance of redislocation 2) Why did this happen?
27 Redislocation Rates 1. Primarily related to age 16 year old - >95% 60 year old - <10% 2. Number of dislocations 3. Tear Size 4. Bone loss - (glenoid, Hills Sachs ) 5. Other - ligament laxity etc.
28 WHY do I do it arthroscopically? Day Surgery in most cases Wound issues rare Less stiffness Can treat other pathology (SLAP, Posterior tears) Recurrence same as Open in most recent studies
29
30 SLAP Tears Give pain by pulling on Long Head Biceps Options 1. Conservative 2. Surgical a. Repair it (Arthroscopic Repair) b. Offload it - cut it (tenotomy) - transfer it (tenodesis)
31
32 What I do 1. Under 40 - arthroscopic repair and working/active etc - Tenodesis 3. >55 Tenotomy 4. Combined with massive cuff tear - tenotomy
33 When to Refer Patient with SLAP tear? Young (<40) That s it!! Older patients usually not the problem
34 Case 3 23 year old - high contact at football He wants to know a. Should he have this fixed? b. Long term issues
35 How would you manage this Grade 3 ACJ dislocation? A. Urgent Surgery B. Sling & physio - 6 weeks C. Collar & Cuff - 3 weeks D. Sling and Re-examine in 2 weeks
36 A. Urgent Surgery B. Sling & physio - 6 weeks C. Collar & Cuff - 3 weeks D. Sling & Re-examine in 2 weeks
37 - Types
38 The patients who fail conservative treatment need a reconstruction (eg. Hamstring graft) as opposed to a repair The patients who opt for operative treatment initially usually need 2 operations (metal in, metal out)
39 What do I do? Low grade (1,2) Sling 1-2 weeks, early physio for mobilisation, weight bear as tolerated Grade 3 Re-examine in 10 days -If moving well, cont. conservative care -If intense pain consider surgery
40 Chronic Case = Hamstring graft The distal clavicle is resected (as it has cartilage wear from repeated motion). A hamstring graft replaces the original ligaments
41 Some Fractures
42 Watch out!!
43 Case 4: 23 yo man 1. Fracture Description 2. Refer? 3. Treatment in clinic - type - duration - expected union time - when mobilise - when xray
44 Case 4: 23 yo man 1. Fracture Description - MIDSHAFT CLAVICLE, DISPLACED 1 DIAMETER, SLIGHTLY SHORT 2. Refer? YES OR NO 3. Treatment in clinic - type - SLING - duration 6 WEEKS - expected union time 10-12WEEKS - when mobilise - WHEN SHOWING SIGNS OF UNION - when xray - 2 WEEKS, 6 WEEKS THEN 4 WEEKLY
45 Case 5: 15 yo boy 1. Fracture Description 2. Refer? 3. Treatment in clinic - type - duration - expected union time - when mobilise - when xray
46 Case 5: 15 yo boy 1. Fracture Description - LATERAL CLAVICLE 2. Refer? YES WHY- HIGH RATE OF NON-UNION
47 56 yo man 1. Fracture Description: MIDSHAFT HUMERUS, ANGULATED 35 DEG 2. Refer? NO 3. Treatment in clinic - type COLLAR & CUFF, THEN BRACE - duration - UNTIL UNITED - expected union time AVERAGE 4 MONTHS - when mobilise 8 WEEKS - when xray - 2 WEEKS, 6 WEEKS, THEN 4 WEEKLY
48 Humeral fracture brace - any orthotists
49 Thank you Questions? Mr. Eden Raleigh Orthopaedic Surgeon Specialising in Shoulder & Knee Surgery Ph:
Shoulder Impingement. Eden Raleigh Orthopaedic Surgeon Shoulder & Knee Surgery. Ph:
Shoulder Impingement Eden Raleigh Orthopaedic Surgeon Shoulder & Knee Surgery Ph: 9421 1900 0402697115 dredenraleigh@gmail.com My Background Specialising in Shoulder and Knee Surgery Main focus on Arthroscopic/Sports
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