Shoulder and Elbow ORTHOPAEDIC SYPMPOSIUM APRIL 8, 2017 DANIEL DOTY MD

Shoulder and Elbow ORTHOPAEDIC SYPMPOSIUM APRIL 8, 2017 DANIEL DOTY MD

Shoulder Articulations Glenohumeral Joint 2/3 total arc of motion Shallow Ball and Socket Joint Allows for excellent ROM Requires soft tissue to maintain reduction and function Scapulothoracic Articulation 1/3 total arc of motion No bony articulation Relies completely upon dynamic muscle function Acromioclavicular joint Links the upper limb to the axial skeleton Allows for some rotational motion of the clavicle during shoulder motion

Glenohumeral Anatomy Scapula: 17 Muscle Attachments Body Acromion Glenoid

Glenohumeral Anatomy Labrum: Circumferential cartilage ring Deepens socket by 50% Critical role in stability Tears can result in pain and/or instability

Glenohumeral Anatomy Long Head of the Biceps Tendon Questionable role in glenohumeral stability Tendonitis/ tears can result in significant pain

Glenohumeral Anatomy Glenohumeral Ligaments Static stabilizers Prevent instability at the extremes of motion Tears allow for instability Inflammation results in pain/stiffness

Glenohumeral Anatomy Rotator Cuff 4 muscles: critical to active function and stability Dynamic stabilizers Center the humeral head in the glenoid throughout ROM Tears result in pain, weakness, varying degrees of dysfunction

Shoulder Pathology typically affects multiple anatomic sites A single problem can set off a chain reaction resulting in dysfunction throughout the shoulder girdle Goals of treatment are to minimize pain while maintaining motion and function Typically requires a concerted, multimodal effort by the physician, therapist, and patient to achieve a good result

Glenohumeral Arthritis Destruction of Cartilage layer Flattening of Humeral Head Bone Spur/Osteophytes Contracture of Anterior capsule Loose Bodies Rotator Cuff Intact

Glenohumeral Arthritis Physical Exam Findings Painful ROM Limited PROM=AROM External Rotation Limited Crepitus Cuff testing typically 4/5 strength

Glenohumeral Osteoarthritis Nonoperative treatment Tylenol Arthritis NSAID S Steroid Injections Activity Modification

Glenohumeral Arthritis Surgical Treatment Anatomic Total Shoulder Arthroplasty Typically utilized for arthropathy with rotator cuff intact

Basics of Anatomic TSA Surgical approach Anteriorly between Deltoid and Pectoralis Major Muscles To Access the Shoulder Joint Subscapularis Must be Released

Basics of Anatomic TSA Anterior Capsule is Released to allow for Ext Rot Humeral Head and Glenoid are resurfaced Long Head of Biceps Tendon tenodesed

Basics of Anatomic TSA *Subscapularis is Repaired*

Principles of Anatomic TSA Rehab Respect Subscapularis repair for 6 weeks Avoid aggressive External Rotation passive stretching Limit to ER may be set by the surgeon based on intraop findings Avoid resisted Internal Rotation Reinforce Patient Education and HEP Maintain Pain Control and Limit Inflammation

Principles of Anatomic TSA Rehab Phase I: Immediate Postop 2wk Sling at all times other than exercises Ice Exercises 3-6 times daily Straight arm hangs Pendulums Codmans NWB Elbow, Wrist, and Hand AROM as tolerated

Principles of Anatomic TSA Rehab Phase II : 2-6 weeks postop Begin outpatient PT Goal to improve PROM Supine FE stretching IR Crossbody Adduction Extension Scapular Strengthening Shoulder Shrugs and Retraction Patient may use the arm for light ADL s, bathing, eating, etc Sling while in public

Principles of Anatomic TSA Rehab Phase III : 6weeks-3months Isometrics of RC transitioning into strengthening of ABD, FE, ER Increase resistance of shrugs, retraction, biceps and triceps Out of sling Encourage ADL s Continue HEP

Pitfalls Postop Anatomic TSA Subscapularis rupture Subscapularis is taken down and repaired in every case This is the limiting factor in post op rehab Poor tissue or repair can place at higher risk of rupture Passive external rotation places highest stress on the repair Gentle stretching in ER and nonresisted active internal rotation with limit set by surgeon is best method for the first 4-6 weeks until healing occurs

Subscapularis Failure Signs of Subscapularis Failure Painful anterior shoulder pop Sudden increase in Passive External Rotation Decrease in Active Internal Rotation power Management Refer back to surgeon for evaluation as soon as possible Early ruptures may be repairable Chronic ruptures with poor function or instability can be treated with pectoralis transfer or reverse shoulder replacement

Subscapularis Failure Typically results in poor outcome and may result in anterior instability and anterior superior escape

Reverse Total Shoulder Arthroplasty FDA approved in US 2003 Originally used for rotator cuff tear arthropathy Indications have expanded rapidly and include cuff deficiency, proximal humerus fractures, revision with bone loss, chronic instability and some patterns of cuff intact arthritis

Reverse Total Shoulder Arthroplasty Creates a fixed fulcrum in the shoulder Allows for a Constrained Joint: imparts stability despite lack of soft tissue restraints Allows the Deltoid to power shoulder motion in the absence of a functional rotator cuff

Rotator Cuff Deficient Shoulder Compression lost Deltoid force results in sheer and superior translation

Basics of Reverse Shoulder Typically performed through anterior approach Often times done in the setting of a deficient subscapularis Subscapularis repair/no repair has not been shown to impact the outcome The operative arm will be lengthened after the procedure and the deltoid will be stretched

Reverse Shoulder Rehab Rehabilitation is similar to that of anatomic TSA but typically at an accelerated pace because there is not a need to protect the subscapularis Focus is to maintain Passive range of motion and strengthen the deltoid for forward flexion and abduction Retraining to allow for ADL s Patients often have difficulty with active external rotation due to loss of posterior rotator cuff

Pitfalls of Reverse Shoulder Arthroplasty Periprosthetic fractures Fall prevention If good bony fixation is achieved at surgery patients can use the implant with a walker Dislocation Despite constraint, instability can be a problem for reverse Avoid extension, internal rotation, adduction and axial load Typical position is reaching behind to push up out of bed or a chair or unfastening a bra Acromial Stress Fractures Increased stress on acromion due to deltoid tension Pt will have point tenderness to acromion Treatment is to hold therapy and rest in a sling

Reverse for Revision, Fracture, Nonunion Rehab may be slower for these situations versus RCTA Fractures: Goal is to limit stiffness while protecting repaired tuberosities 67 y M s/p bicycle crash with right proximal humerus fracture

Reverse for Nonunion 67 yo F with a Nonoperatively treated proximal humerus fracture nonunion

Elbow Basics General Elbow Principles Normal Arc of motion is 0-145 Functional Arc of motion is 30-130, 45-45 pronation/ supination Post traumatic elbow tends to lose extension Position of stability is flexion and pronation

Elbow Basics Active motion compresses the joint and typically improves stability Passive motion can distract the joint Supine active elbow flexion and extension is a good method to avoid distraction and work on motion Work on Pronation and Supination with the elbow flexed to 90 degrees Work on Flexion and Extension with the forearm in neutral or pronation Avoid coupled extension and supination in the early recovery period

Elbow Case 30 yo F falls from 3 feet landing on outstretched arm Radial Head Shear fracture and coronoid tip fracture indicate a fracture dislocation

Intraop pivot shift test indicating rupture of the lateral ligaments resulting in posterolateral rotatory instability Elbow Case

Repair Radial Head Repair lateral ligament complex

Postop Management Splint for 1 week Ice, elevate, limit swelling Begin ROM after 1 week Supine Active flexion and extension with forearm in neutral Pronation/Supination active and passive with elbow flexed to 90 degrees Avoid supination and full extension If needed limit extension to 30 degrees for first 3 weeks Light ADL s at 6-8 weeks postop Activity as tolerated 3 months

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