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1 Shoulder Problems Fractures Instability Impingement Miscellaneous

2 Anatomy Bones Joints / Ligaments Muscles Neurovascular

3 Anatomy

4 Anatomy Supraspinatus Anterior Posterior

5 Anatomy

6 Neurovascular Anatomy

7 Anatomy:Joints Acromioclavicular Glenohumeral Sternoclavicular Scapulothoracic

8 Shoulder problems : History Onset,duration,location??trauma radiation of pain?c-spine problems instability, dead arm repetitive use

9 Physical Examination deformity eg AC sep n ROM passive & active Impingement tests Instability tests neurovascular exam

10 Shoulder Problems Acute Pain? Trauma Fractures Neer Classification Dislocations AMBRI & TUBS Inflammation Calcific Septic

11 Trauma!!

12 Fractures Clavicle Proximal Humerus Scapula / Glenoid

13 Clavicle Fractures Common Most heal uneventfully Figure of 8 x 6 weeks Beware of high energy ie MVA Assoc d d soft tissue

14 CLAVICLE FRACTURE

15 Clavicle Fractures : Figure 8 bandage

16 Proximal Humerus Fractures Neer- 4 parts Vascularity of articular fragment Displacement > 1 cm Angulation > 45 degrees Xray vs. CT scan Interobserver variability

17 Fractures : The Four Parts

18 Fractures

19 Proximal Humerus Fractures Treatment Undisplaced & 2-part 2 : Sling 3- part : ORIF 4- part : Prosthesis

20 4 PART FRACTURE

21 NEER PROSTHESIS

22 3 PART FRACTURE

23 ORIF 3 PART

24 Fractures :Scapula / Glenoid Rare Most treated conservatively Intraarticular displacement may need ORIF

25 Shoulder Instability Traumatic vs. Habitual Unidirectional vs. Multidirectional Unilateral vs. Bilateral

26 Anterior Shoulder Instabliity Hx of significant trauma Very Painful Most common Nerve injury esp. axillary Xray : Hill-Sachs defect

27 The Y lateral Xray

28 The Y lateral Xray

29 Bankart and Hill-Sach Sach s lesions

30 Anterior Shoulder Instability Needs urgent reduction Muscle relaxation,traction,patience Post reduction exam(neuro) ) & Xray Gilchrist sling Tell patient recurrence risk recurrent dislocation requires surgery

31 Anterior dislocation ;reduction

32 Anterior Shoulder Instability Surgery involves repair of torn anterior structures Bankart lesion High success rate with several different procedures

33 Anterior Shoulder Instability Traumatic Unidirectional Bankart Surgery

34 Multidirectional Instability anterior,posterior,inferior voluntary atraumatic ligament laxity some are assoc d with psychological problems

35 Multidirectional Instability Atraumatic Multidirectional Bilateral Rehabilitation Inferior Capsular Shift (RARELY)

36 Acromioclavicular Separations Hockey, bikes Coracoclavicular & Acromioclavicular ligaments Grade 1-61 Most treated conservatively Late excision of outer end of clavicle

37 The Clavicular Ligaments

38 Acromioclavicular Ligaments

39

40 Inflammation:Calcific Tendonitis Acute occ. severe pain Mimics infection Marked decrease ROM Xray : Fluffy density near greater tuberosity NSAIDS

41 Calcific Tendonitis

42 Inflammation Septic Gout RA flare-up

43 Shoulder Pain : Chronic Chronic Shoulder Pain Impingement Syndromes Rotator cuff tendonitis cuff tears AC arthritis Osteoarthritis Rheumatoid Arthritis AVN Frozen Shoulder Benign tumors Malignant tumors primary secondary

44 Impingement Syndromes Subacromial bursitis Rotator cuff tendonitis Bicipital tendonitis AC arthritis Rotator cuff tear

45 Impnigement : Anatomy

46 Acromion Morphology

47 Impingement : Supraspinatus

48 Impingement :Hx & Px Repetitive overhead use of arm Swimmers,pitchers painful arc impingement signs decreased ROM active vs. passive pain with resisted motion

49 Impingement : treatment Avoidance of offending activity Physiotherapy NSAIDS Corticosteroid injection Surgery : Subacromial decompression

50 Impingement : Imaging Xrays : often normal Xrays : shape of acromion Arthrogram MRI MSK Ultrasound

51 MRI ROTATOR CUFF

52 Impingement :Surgery Arthroscopic vs open decompression Cuff repair Excision outer end of clavicle

53 Impingement : Acromioplasty

54 Rotator Cuff Repair

55 Frozen Shoulder primary vs. secondary prolonged stiffness usually self-limited limited lasts up to 2 years physio/injection manipulation benign neglect

56 RA Shoulder usually obvious diagnosis joint and tendon damage steroid injections synovectomy Total shoulder arthroplasty

57 OA & AVN uncommon end stage can be treated by arthroplasty AVN risk factors

58 OA SHOULDER

59 Tumors primary relatively rare always think of metastatic disease in patients > 50 night pain Xray : bone destruction

60 Tumors

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