The Shoulder. By Patrick Ryan, Bobby Law, Jack Beaty, Alex Newhouse and Chuck Nelson

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1 The Shoulder By Patrick Ryan, Bobby Law, Jack Beaty, Alex Newhouse and Chuck Nelson

2 Learning Objectives/Agenda Review the anatomy of the shoulder Describe the main diseases of the shoulder Describe the main injuries of the shoulder

3 Shoulder Joint Ball and Socket 3 joints: Glenohumeral Joint (GH) Sternoclavicular Joint (SC) Acromioclavicular Joint (AC)

4 Bones of the Shoulder Scapula Humerus Clavicle

5 Ligaments Surrounding Shoulder Coracohumeral ligament Glenohumeral ligament Acromioclavicular ligament Coracoclavicular Ligament Coracoacromial ligament

6 Muscles Surrounding Shoulder Deep Muscle Group (Rotator Cuff) Supraspinatous Infraspinatous Subscapularis Teres Minor Primary function: to keep the humeral head inside of the glenoid fossa cavity.

7 Muscles Surrounding Shoulder Deltoid Abducts the shoulder Pectoralis Major Adducts the shoulder Latissimus Dorsi Transverse extension of the shoulder Teres Major Helps with the extension of shoulder

8 Exercises to Strengthen the Shoulder (Pull up vs. Chin up)

9 Diseases Osteoarthritis Subacromial Bursitis Frozen Shoulder Milwaukee Shoulder Autoimmune disorders

10 Osteoarthritis Most common type of arthritis in the shoulder Causes: Progressive wear & tear of cartilage around glenohumeral joint Symptoms: Pain, swelling, stiffness, tenderness, limited range of motion Treatment:

11 Subacromial Bursitis Swollen bursa between rotator cuff tendons and acromion Causes: Repetitive minor trauma or tendonitis Symptoms: Pain felt between and degrees up/outward Treatment: Rest Hot/Cold therapy NSAIDs

12 Frozen Shoulder Also called Bones, ligaments, and tendons of shoulder are encapsulated by scar/connective tissue. Causes: Lack of shoulder motility or trauma Symptoms: Reduced range of motion and pain in all directions Treatment: NSAIDs PT Surgery

13 Milwaukee Shoulder Syndrome Deposition of crystals in the synovial fluid. Crystals slowly scratch away cartilage in glenohumeral joint Causes: Currently unknown but occurs mostly in women over 60 Symptoms: Pain, tenderness, synovial fluid swelling with no inflammation response (no leukocytes) Treatment: Aspiration, NSAIDs, Surgery

Causes : Mostly unclear, but likely genetic Symptoms: Pain, swelling,

14 Autoimmune Diseases Rheumatoid Arthritis Body attacks tissue synovium Lupus Antibodies created to attack Deltoid muscle or joint itself Causes : Mostly unclear, but likely genetic Symptoms: Pain, swelling, stiffness, weakness, rash (Lupus) Treatment: NSAIDs, Steroid injections

older individuals when falling Almost always in anterior/inferior direction,

15 Dislocation Most commonly dislocated joint After dislocation(s) more susceptible to future dislocation More common in young males involved in sports as well as older individuals when falling Almost always in anterior/inferior direction, because of superior support by acromion coracoid process, and rotator cuff Anterior dislocation

Reduction Procedure Patient must be relaxed Elbow bent at 90 degrees Externally rotate until resistance is felt Lift arm in sagittal plane as much as possible

16 Reduction Procedure Patient must be relaxed Elbow bent at 90 degrees Externally rotate until resistance is felt Lift arm in sagittal plane as much as possible Internally rotate arm across body and humeral head should slip back into glenoid Pain should decrease significantly once humeral head is back in place Kocher s Method

Labral Tears Slap Tear Bicep tendon pulls labrum off of glenoid Typically extends from 10 o clock to 2 o clock position Treatment: PT, anti-inflammatory drugs, termination of throwing activities,

17 Labral Tears Slap Tear Bicep tendon pulls labrum off of glenoid Typically extends from 10 o clock to 2 o clock position Treatment: PT, anti-inflammatory drugs, termination of throwing activities, arthroscopic surgery Bankart Lesions Usually result of shoulder dislocation Occurs from 3 o clock to 6 o clock position because that is where humeral head dislocates in an anterior dislocation Treatment: Arthroscopic surgery, as redislocation rates are 80-90% and the surgery is 90-95% effective

18 Labral Tear MRIs Bankart Lesion

Rotator Cuff Tears Rotator cuff is made up of 4 muscles that act as tendons, covering the head of the humerus and helping to raise and rotate arm Most RC tears occur in supraspinatus tendon, but

19 Rotator Cuff Tears Rotator cuff is made up of 4 muscles that act as tendons, covering the head of the humerus and helping to raise and rotate arm Most RC tears occur in supraspinatus tendon, but others can be involved too 2 main causes: Injury and Degeneration Injury: Falling on outstretched arm or pulling something too heavy with a jerking motion can result in an acute tear Degeneration: Repetitive motions, lack of blood supply and bone spurs can result in degenerative tear Healthy RC Torn RC

20 Is Joint Replacement for You? Osteoarthritis Rheumatoid Arthritis Post Traumatic Arthritis Avascular Necrosis Severe Bone Trauma

21 Shoulder Replacement Surgery Three Methods Total Shoulder Replacement Shoulder Hemiarthroplasty Reverse Total Shoulder Replacement

Total Shoulder Replacement(TSR) Involves replacing joint surfaces with a metal ball attached to a stem and a plastic socket. Use either pressed fit or cement fit depending on patient.

22 Total Shoulder Replacement(TSR) Involves replacing joint surfaces with a metal ball attached to a stem and a plastic socket. Use either pressed fit or cement fit depending on patient. Most cases, all plastic glenoid socket is implanted with bone cement. Good candidacy includes bone osteoarthritis or intact rotator cuff tendons. Avoid glenoid component if: Good cartilage still present Glenoid bone is deficient Rotator cuff tendons are irreparably torn

23 Reverse Total Shoulder Replacement Metal ball is attached to glenoid cavity and socket is attached to humeral head Allows for usage of deltoid rather than rotator cuff Used for people who: Have completely torn rotator cuff Severe arthritis or cuff tear arthropathy Previous failed TSR

24 Shoulder Hemiarthroplasty Similar to TSR, but only replaces the ball. Stemmed arthroplasty includes replacing head of humerus with a metal ball and stem. Used when humeral head is severely fractured but socket is normal. Other indications include: Arthritis only on humeral head with intact glenoid cartilage Severely weakened glenoid bone Severely torn rotator cuff tendons Resurfacing hemiarthroplasty replaces only joint surface of humeral head. Advantages include to avoid component wear and loosening. Indications include: Glenoid cartilage still intact Has been no fresh fracture of humeral head

25 Quiz Answers 1. Scapula 2. Subacromial Bursitis 3. Deltoid 4. Humeral Head 5. Frozen Shoulder 6. Ball and Socket 7. A: Coracoacromial ligament B: Coracohumeral ligament C: Glenohumeral ligament D: Coracoclavicular Ligament 8. (left to right) - Humerus - Scapula - Clavicle

Shoulder Joint Replacement

Shoulder Joint Replacement Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain. Shoulder replacement surgery was first performed