anatomy, diagnosis and classification of sports injuries in the shoulder
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Anatomy, diagnosis and classification of sports injuries in the shoulder. Mr. Nnamdi Obi Specialist registrar United Kingdom. Objectives. Review anatomy of the shoulder Review history and examination Acute traumatic shoulder instability. Introduction. Instability Glenohumeral dislocation - PowerPoint PPT PresentationTRANSCRIPT
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Anatomy, diagnosis and classification of sports injuries in the
shoulderMr. Nnamdi Obi
Specialist registrar
United Kingdom
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Objectives
• Review anatomy of the shoulder
• Review history and examination
• Acute traumatic shoulder instability
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Introduction
• Instability– Glenohumeral dislocation
• SLAP tears
– ACJ dislocation
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30 YO male,Professional Rugby payer, first episode
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Anatomy• Synovial ball and socket
joint
• Articular surface covered with hyaline cartilage
• Glenoid cavity deepened by labrum
• Articulations
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Rotator cuff
• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis
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Ligaments• Glenohumeral
– Superior Glenohumeral ligament– Middle Glenohumeral Ligament– Inferior Glenohumeral Ligament
• Shoulder girdle– Coraco clavicular– ACJ proper– Acromioclavicular
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Biomechanics
Static restraints
•Glenoid labrum
•Articular version + conformity
•Glenohumeral ligaments
•Negative intra-articular pressure
Dynamic restraints
• Rotator cuff muscles
• Biceps tendon
• Scapular stabilizers
• Neuromuscular factors
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History(Acute traumatic instability)
• Age• Mechanism
• Traumatic• Atraumatic
• Chronicity– Ease of dislocation
• Expectations• Return to play
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Examination
• Acutely– Pain limits most– Pre and post axillary nerve function
• Sensory• Motor
• Delayed• Hyperlaxity – predisposing• Provocative tests• Labral pathology (SLAP tear)
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Sulcus sign
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Apprehension
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Relocation test
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• O’Brien’s
Labrum (SLAP)
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• Load & Shift
Labrum
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Special investigations
• Bones– Glenoid– Head humerus
• Soft tissues– Rotator cuff– Labrum
X Ray CT scan
Ultrasound – no labrumMRI
MRI arthrogram
CT arthrogram
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Lateral radiographs• Posterior oblique scapular projection (“Neer lateral”, Neer 1970)
– Produces considerable image overlap• Transthoracic (Vastamaki and Solonen 1980)
– Image overlap• Axial (Warrick 1965)
– Requires shoulder abduction• Modified axial (Rockwood 1984)
– Some shoulder abduction• Velpeau lateral (Wallace and Hellier 1983)
– Patient needs to sit up• Apical oblique (Garth, Slappey and Ochs 1984)
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J Bone Joint Surg [Br] l988;70-B:457-60.
This is posterior dislocationBut outlines glenoid and humeral head
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Almost normal AP
Axial viewSmall Hills sachsAnterior glenoid Fine
Same patient Apical obliqueLarge Hills sachsBlunting anterior glenoid
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- Plain x-ray
- CT
- CT recon
Bone loss
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30 YO male, football, first episode
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How long ?
Treatment
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• MRI study– IR Labrum off glenoid– ER tension rests on glenoid
• Randomized 40 pts– Sling IR Vs ER– Recurrence
• IR 6/20, 30%• ER 0/20
J Shoulder Elbow Surg 2003;12: 413-15
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JBJS – B VOL. 91-B, No. 7, JULY 2009
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• Premise– Younger = recurrent instability = immobilize longer– Older = stiffness = mobilize sooner
• No benefit to immobilization in internal rotation > 1 week in pts under 30 yrs of age
• Age of less than thirty years at time of injury predicts increased recurrence.
• Best available evidence does show a clinical benefit to treatment in external rotation over conventional sling immobilization, but this advantage did not reach significance
• BUT most ITOI
J Bone Joint Surg Am. 2010;92:2924-33
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Take Home
• Reduce• Sling comfort
• Discard in 1 week• Physiotherapy, strengthen dynamic stabilizers
• Under 30 years, continue contact sport• Counsel recurrence rate• Consider surgery following first dislocation
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SLAP Lesions• May be associated with
dislocation but commonly due to pull on the arm, weightlifting, throwing, tackling
• Symptoms – clicking, pain with overhead activities
• Clinically – pain with eccentric biceps loading (e.g. going down on bench press)
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SLAP lesion classification
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Acromioclavicular joint (ACJ) injuries
• Usually injured by a direct fall onto the point of the shoulder
• Scapular forced downwards
• Clinically, lateral end of clavicle prominent
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30 YO rugby player again
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Classification of ACJ Injuries (Rockwood)
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Treatment
• Non Operative– Grade 1-3
• Operative– Grade 4-6
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Conclusions
• Acute instability common in athletes– Glenohumeral– ACJ
• High level of function
• Early return to play
• Axillary or modified axillary view– Apical oblique
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References
• Websites:– https://www.shoulderdoc.co.uk– https://www.orthobullets.com