shoulder instability
TRANSCRIPT
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Dr. Atif Shahzad PGR
Orthopedic Dept. SHL
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DEFINITION:Instability:• Inability to maintain the humeral head in the glenoid
fossa.
• Includes a spectrum of disorders
Dislocation
Complete loss of glenohumeral articulation
Subluxation
Partial loss of glenohumeral articulation with symptoms
Laxity
Incomplete loss of glenohumeral articulation
unassociated with pain
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STABILITYStatic Factors
Articular Congruence
Articular Version
Glenoid Labrum
Capsule and Ligament
Dynamic Factors
Rotator Cuff
Biceps Tendon
Scapulothorasic Motion
Negative Pressure
Propioception
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OSTEOLOGY Glenoid fossa
Pear shaped
7 deg. of retroversion
5 deg. of sup tilt
Glenoid version
30o anterior
Humerus
Neck-shaft – 130o to 140o
Retrotorsion – 30o
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GLENOHUMERAL JOINT Humeral head 3x larger
than glenoid fossa
Ball and socket with translation
3 degrees of freedom
Flex/Ext
Abd/Add
Int/Ext rot
Plus
Cricumduction
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GLENOID LABRUM Static stabilizer
contributes 20% to GH stability
Fibro cartilaginous tissue
Deepens glenoid(50%)
3purposes:
Inc. surface contact area
Buttress
Attachment site for GH ligaments
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CAPSULE AND LIGAMENTSCapsule
Attached medially glenoid fossa
laterally to anatomical neck of humerus
Ant cap thicker than post.
2-3 mm of distraction
Little contribution to joint stability
Strengthened by GHLs and RC tendons
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GLENOHUMERAL LIGAMENTS(Superior, Middle , Inferior)
SGHL
O = tubercle on glenoid just post to long head biceps
I = upper end of lesser tubercle
Resists inf. subluxation and contributes to stability in post and inf. directions
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MGHL
O= sup glenoid and labrum
I = blends with subscapularis tendon
Limits ant. instability especially in 45 deg abduction position
Limits ext rotation
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IGHL
O= ant. glenoid rim and labrum
I= inf. aspect of humeral articular surface and anatomic neck
3 bands, anterior, axillary and posterior
Acts like a sling ,the most important single ligamentous stabilizer .
Primary restraint is at 45-90 deg abduction.
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Coracoacromial ligament
secondary stabilizer.
Coracohumeral ligament
Contribute to restraining inferior subluxation with arm at side,
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Dynamic Factors
Rotator Cuff
Biceps Tendon
Negative Pressure
Scapulothoracic motion
Proprioception
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ROTATOR CUFF Compression enhances conformity
Greater than static stabilizers
Coordinated contractions/steering effect
Supraspinatus most important
Dynamization
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Biceps long head, Deltoid
secondary stabilizer head depressor
Periscapular Muscles
help position scapula and orient glenohumeral jointcontributes compressive force across joint
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SCAPULOTHORACIC MOTION 2:1 glenohumeral to scapulothoracic motion
Scapulothoracic muscle (trapezius, serratus anterior, teres major, levator scapulae)
less stable platform
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NEGATIVE INTRA-ARTICULAR PRESSURE -42 cm H2O in cadaver
Secondary to high osmotic pressure in interstitial tissues
Only clinically important in the arm at rest in adduction
Lost with lax capsule or defect
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PATHOANATOMY OF SHOULDERINSTABILITY
Laberal Lesions – Bankart – Reverse Bankart – SLAP lesions
Capsular Injury – Intrasubstance Tear – HAGL – Capsular Laxity
Bone Loss – Glenoid – Humeral Head-Hill-Sachs Lesion
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BANKART LESION.
The traumatic detachment of the glenoid labrum has been called the Bankart lesion. 85%
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HILL-SACHS LESION
This is a defect in the posterolateral aspect of the humeral head.
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INSTABILITYClassification:
Frequency
Etiology
Direction
Degree
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Frequency Acute
Recurrent
Fixed (chronic)
Etiology Traumatic event (macrotrauma)
Atraumatic event (voluntary, involuntary)
Microtrauma
Congenital condition
Neuromuscular condition (epilepsy, seizures)
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Directions of instability
Anterior
Posterior
Inferior
Superior
Multidirectional
Degree
Subluxation
Dislocation
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SPECTRUM
Traumatic Microtrauma Atraumatic
Less laxity More laxity
Unidirectional Multidirectional
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EVALUATION OF INSTABILITYHistory Age
Trauma-Duration
Associated Pain
Sports, throwing or overhead activities
Voluntary subluxation
“Clunk” or knock
Fear-Limitation of Movements
Hx dislocationsand energy associated
Hx 1st dislocation or injury
Subsequent dislocations/ subluxations
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Physical Examination
Inspection
Palpation
ROM
Winging
Neurovascular testing
Generalized ligamentous laxity
Instability tests
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Sulcus sign
Drawer tests
Load & Shift test
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Apprehension test
Jobe’s Relocation
Jerk test
Fulcrum
Grade = 1 - 4
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DIAGNOSIS X-rays
CT Scan
MRI
Arthroscopy
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RADIOLOGY X-Rays
Identify Bankart or Hill-Sachs Lesion
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AP VIEW
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Axillary View
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Scapular Y-View
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Stryker view Humeral Head Defect
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Apical Oblique view Glenoid rim lesion
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West Point Axillary view Anteroinferior glenoid rim
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ANTERIOR DISLOCATION97% of recurrent dislocation
abduction, extension and
external rotation
subcoracoid
subglenoid
subclavicular
Associated Injuries:
Fractures
Head & Neck
Rotator Cuff Tears > 40 y/o = 30 %
> 60 y/o = 80%
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Neurologic Injury
Axillary nerve
10-25% incidence 1st time.
2-5% in recurrent dislocators
Tx: “watchful expectancy”
Poor prognosis if no recovery by 10 wks
Vascular Injury
Axillary artery
2nd part thoracoacromial
trunk
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TREATMENTNONOPERATIVE
Closed Reduction
Immobilization-Sling
Analgesics
Rehabilitation
ROM
Strengthening exercises
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Treatment of 1st time dislocators :
2 groups
Immobilize x 4wks
80% recurrence
Surgical repair
14% recurrence
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TREATMENT OF RECURRENT ANT. DISLOCATION
Non-operative Tx:
Only 16% traumatic respond
80% atraumatic respond
Poor response to non operative Tx
Surgical stabilization
Open or arthroscopic
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MATSEN'S CLASSIFICATION TUBS:
Traumatic
Unidirectional
Bankart lesion
Surgery is often necessary.AMBRI:
Atraumatic
Multidirectional
Bilateral
Rehabilitation is the primary mode of treatment.
Inferior capsular shift & internal closure often performed.
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OPERATIVE TREATMENT:Capsulolabral Repair
Bankart
Modified Bankart
Subscapularis Procedures
Putti-Platt
Magnuson-Stack
Coracoid Transfer Procedures
Bristow
Latarjet
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POSTERIOR DISLOCATION
Incidence: < 5% all shoulder dislocations
3% of recurrent
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Mechanism:
Axial load
Flexed/Adduction
Bench press-“lock out”
Swimming- pull thru
Rowing
Football Offensive Lineman
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Examination
Shift & load test
Post. Apprehension test
Jerk test
Kim test
Imaging studies
X-ray
CT
MRI
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TREATMENTNon Operative
Immobilization
Protection
Rehabilitation
70-90% improve
Functional disability
improved
Instability not eliminated
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Operative Management
Overall 50-95 % success
Higher recurrence vs ant. instability procedures
Soft Tissue Procedures
Posterior Capsulorrhaphy
Reverse Putti-Platt
(IS Capsular Tenodesis)
McLaughlin
Bone Procedures
Posterior Glenoid Osteotomy
Posterior Bone Block
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REHABILITATION1. Immobilization in first 4 weeks
No ext rotation
Abduction less than 45°
Isometric resistance exercises
2. Graduated in 4 – 8 weeks
↑ ROM
Graduated weight training
3. Return to sport
Non contact = 6 weeks
contact = 12 weeks
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THANKS