Complex Interplay of 4 Joints

Complex Interplay of 4 Joints

The Shoulder

  1. Anatomy
  2. Complex interplay of 4 joints
  3. Synovial Joints

  1. Gleno-humeral
  2. Sterno-clavicular
  3. Acromio-clavicular

  1. Gliding Joint
  2. Scapulo-Thoracic
  1. Bony Anatomy
  2. Clavicle
  3. Humerus

  1. Head
  2. Shaft
  3. Greater Tuberosity
  4. Lesser Tuberosity

  1. Scapula

  1. Glenoid
  2. Acromion
  3. Body
  4. Spine

  1. Ligaments

  1. Gleno-humeral
  2. Acromio-clavicular
  3. Coraco-acromial
  4. Coraco-clavicular

  1. Bursa

  1. Subacromial
  2. Subdeltoid

  1. Muscles
  2. Inner sleeve-Rotator cuff

  1. Subscapularis- Internal rotator
  2. Supraspinatus- abductor
  3. Infraspinatus- external rotator; abductor
  4. Teres minor- external rotator
  5. Biceps (long head)

  1. Outer sleeve-Deltoid

  1. Pectoralis major
  2. Latissimus dorsi
  3. Teres major

  1. Scapula muscles
  1. Nerves
  2. Brachial plexus
  3. Axillary nerve- major nerve to the shoulder
  4. Musculocutaneous nerve- innervates the biceps
  1. Biomechanics
  2. Stability
  3. Function of the Rotator Cuff
  4. Delto-supraspinatus force couple
  5. Motion
  6. Gleno-humeral: scapula-thoracic
  7. Clavicle rotation
  8. Shoulder Exam
  9. History

  1. Trauma- mechanism of injury
  2. Pain- where, when, how long
  3. Function

  1. Physical exam
  2. Inspection
  3. Palpation
  4. Range of motion- active
  5. Strength
  6. Abduction- Supraspinatus/deltoid
  7. Internal rotation- Pectoralis major/Subscapularis/Latissimus dorsi
  8. External rotation- teres minor, Infraspinatus
  9. Sensation
  10. Axillary nerve-deltoid
  11. Median nerve- middle finger, palm side
  12. Ulnar nerve- 5th digit
  13. Radial nerve- first web space dorsal side
  14. Mucocutaneous nerve-top of forearm
  15. Special tests

  1. Apprehension
  2. Impingement sign
  3. Abduction sign
  4. Adduction sign

  1. Roentgenographic exam
  2. Trauma series- AP, Y view( a 40 degree lateral view for the shoulder)
  3. Axillary view- shot with arm up
  4. Stress views
  5. Arthrogram- contrast in the joint; MRI used more often now
  6. MRI- Can show tears of rotator cuff
  1. Clavicle Fractures
  2. The clavicle is the only bony structure that suspends the scapula and the arm from the axial skeleton (most commonly fractured bone in the body)
  3. Mechanism of injury
  4. Falls

  1. Outstretched arms
  2. Falling on side

  1. Classification

  1. Mid-third- 80%
  2. Distal-15%
  3. Inner third- 5%

  1. Signs and symptoms
  2. Arm held against chest
  3. Tender at fracture site
  4. Palpable deformity
  5. X-rays
  6. Treatment

  1. Sling (swathe)
  2. Figure of eight
  3. Shoulder spica cast
  4. Surgery- O.R.I.F

  1. Complications

  1. Neurovascular- can injure brachial plexus
  2. Malunion
  3. Nonunion
  4. Post-traumatic arthritis

  1. Injuries to the acromioclavicular joint (separated shoulder)
  2. A-C joint
  3. Acromioclavicular ligament
  4. Coracoclavicular ligament
  5. Mechanism of injury
  6. Classification- measures displacement on clavicle and acromion
  7. Type I- all ligaments function with no displacement
  8. Type II- ac ligaments torn but Coracoclavicular ligaments intact
  9. Type III- everything is torn
  10. Type IV, V, VI
  11. Signs and symptoms
  12. Joint tenderness
  13. Joint swelling
  14. Deformity
  15. X-rays
  16. Stress views-upright
  17. Treatment

  1. Shoulder harness (Kenny Howard Type)
  2. Sling
  3. Surgery

  1. Complications
  2. Chronic instability- small percentage never heal properly
  3. A-C joint arthritis
  1. Injuries to the Sternoclavicular joint
  2. Uncommon injury
  3. Large force, direct or indirect, to the shoulder
  4. Commonly in MVAs
  5. Classification

  1. Anterior dislocation
  2. Posterior dislocation- uncommon
  3. Traumatic vs. atraumatic

  1. Signs and symptoms
  2. Pain
  3. Deformity
  4. Posterior dislocation may have SOB, choking sensation
  5. X-rays
  6. Special views
  7. C-T scan, tomograms
  8. Treatment
  9. Posterior dislocation requires treatment immediately
  10. Closed reduction- anesthesia
  11. Towel clip reduction
  12. Figure of eight cast
  13. Sling
  1. Glenohumeral dislocation- traumatic
  2. Anterior shoulder dislocation-97%

  1. Subcoracoid
  2. Subglenoid
  3. Subclavicular and intrathoracic- very rare

  1. Mechanism
  2. Direct force
  3. Indirect force- abduction-external rotation
  4. Signs and symptoms
  5. Severe pain
  6. Arm slightly abducted and externally rotated
  7. Squared off appearance of shoulder
  8. Anterior shoulder fullness
  9. Positive apprehension signs- recurrent dislocation
  10. X-rays
  11. AP
  12. Y view
  13. Axillary view
  14. Hill-Sachs lesion- Glenoid makes impaction fracture in humeral head
  15. Seen in patients with multiple dislocations
  16. Bankart lesion- Ligaments tears a piece of bone off of the glenoid during a dislocation
  17. Pathognomonic of dislocations
  18. Treatment

  1. Closed reduction
  2. IV sedation
  3. Shoulder immobilization
  4. Rehab

  1. Complications
  2. Recurrence- especially with young people
  3. Nerve injury- axillary nerve
  4. Fracture
  1. Posterior Shoulder dislocation- 1-3%- very rare
  2. Mechanism of injury
  3. Direct force
  4. Indirect force
  5. Electric shock
  6. Seizure- must be aware of posterior dislocations
  7. It is more common to have an anterior shoulder dislocation during a seizure
  8. Signs and symptoms
  9. Over 60% missed on initial exam
  10. Arm in fixed adduction and internal rotation
  11. External rotation is blocked
  12. Anterior aspect of shoulder flat
  13. Coracoid process prominent
  14. X-rays
  15. Treatment
  16. Closed reduction
  17. Open reduction
  18. Sling
  19. Orthosis/cast
  20. Complication
  21. Missed diagnosis- very common to miss
  22. Fractures
  23. Impingement Syndrome- most common shoulder complaint; shoulder pain with arm elevation
  24. Other names/causes
  25. Painful arc syndrome
  26. Bursitis
  27. Tendonitis
  28. Rotator Cuff Tears
  29. Biceps Tendon Ruptures
  30. Stages
  31. Stage 1- Acute inflammation (overuse type; younger person)
  32. Stage 2- Chronic (fibrosis, collagen failure; over 40)
  33. Stage 3- Rupture of biceps and rotator cuff
  34. Failure of rotator cuff; extension of stage 2
  35. Stress fracture
  36. Stage 4- Cuff tear arthropathy
  37. Mechanism
  38. Related to repetitive overhead activities
  39. Acute injury to rotator cuff
  40. Bony changes
  41. Signs and symptoms
  42. Pain with overhead activities
  43. Night pain
  44. Decreased function in elevation
  45. Positive impingement sign, abduction test
  46. Impingement test- inject lidocaine into subacromial space
  47. Relief of pain is indicative of impingement
  1. X-rays
  2. Arthrogram
  3. MRI
  4. Treatment
  5. NSAIDs
  6. Activity modification
  7. Physical therapy- strengthen rotator cuff
  8. Sub-acromial injection-cortisone
  9. Surgery
  10. Acromioplasty
  11. Rotator cuff repair
  1. Adhesive Capsulitis- frozen shoulder

  1. Women
  2. 40s
  3. Nondominate arm
  4. +/- history of trauma
  5. Neck pain
  6. Insidious onset
  7. Signs and symptoms
  8. Limited ROM in all planes
  9. Pain at the end of ROM
  10. X-rays
  11. Normal
  12. Arthrogram
  13. Treatment
  14. NSAIDs
  15. Physical therapy
  16. Time
  17. Manipulation under anesthesia

  1. Arthritis
  2. Wear and tear-osteoarthritis
  3. Rheumatoid arthritis
  4. Uncommon in the shoulder (G-H joint)
  5. Usually affecting the A-C joint
  6. Signs and symptoms

  1. Inflammation of the joint
  2. Swelling
  3. Pain
  4. Stiffness

  1. Treatment
  2. Resection of clavicle- for AC joint
  3. Anti-inflammatory agents
  4. Shoulder replacement- For G-H joint arthritis
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