Shoulder Trauma Disorders Turhan zler MD Assistant Professor

Shoulder Trauma & Disorders Turhan Özler MD. Assistant Professor Yeditepe University Faculty of Medicine Department of Orthopaedics & Traumatology

Clavicle Fractures

Clavicle Fractures üMechanism üFall onto shoulder (87%) üDirect blow (7%) üFall onto outstretched hand (6%)

Clavicle Fractures ü Clinical Evaluation ü Inspect and palpate for deformity/abnormal motion ü Thorough distal neurovascular exam ü Auscultate the chest for the possibility of lung injury or pneumothorax ü Radiographic Exam ü AP chest radiographs. ü Clavicular 45 deg A/P oblique X-rays ü Traction pictures may be used as well

Clavicle Fractures üAllman Classification of Clavicle Fractures üType I Middle Third (80%) üType II Distal Third (15%) üType III Medial Third (5%)

Clavicle Fracture üClosed Treatment üSling or 8 bandage immobilization for usually 3 -4 weeks with early ROM encouraged üOperative intervention üFractures with neurovascular injury üFractures with severe associated chest injuries üOpen fractures üGroup II, type II fractures üCosmetic reasons, uncontrolled deformity üNonunion

Clavicle Fractures üAssociated Injuries üBrachial Plexus Injuries üContusions most common, penetrating (rare) üVascular Injury üRib Fractures üScapula Fractures üPneumothorax

Shoulder Dislocations

Shoulder Dislocations üEpidemiology üAnterior: Most common üPosterior: Uncommon, 10%, Think Electrocutions & Seizures üInferior (Luxatio Erecta): Rare, hyperabduction injury

Shoulder Dislocations üClinical Evaluation üExamine axillary nerve (deltoid function, not sensation over lateral shoulder) üExamine M/C nerve (biceps function and anterolateral forearm sensation) üRadiographic Evaluation üTrue AP shoulder üAxillary Lateral üScapular Y üStryker Notch View (Bony Bankart)

Shoulder Dislocations üAnterior Dislocation Recurrence Rate üAge 20: 80 -92% üAge 30: 60% ü> Age 40: 10 -15% üLook for Concomitant Injuries üBony: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater Tuberosity Fracture üSoft Tissue: Subscapularis Tear, RCT (older pts with dislocation) üVascular: Axillary artery injury (older pts with atherosclerosis) üNerve: Axillary nerve neuropraxia

Shoulder Dislocations üAnterior Dislocation üTraumatic üAtraumatic (Congenital Laxity) üAcquired (Repeated Microtrauma)

Shoulder Dislocations üPosterior Dislocation üAdduction/Flexion/IR at time of injury üElectrocution and Seizures cause overpull of subscapularis and latissimus dorsi üLook for “lightbulb sign” and “vacant glenoid” sign üReduce with traction and gentle anterior translation (Avoid ER arm Fx)

Shoulder Dislocations üInferior Dislocations Luxatio Erecta üHyperabduction injury üArm presents in a flexed “asking a question” posture üHigh rate of nerve and vascular injury üReduce with in-line traction and gentle adduction

Shoulder Dislocation üTreatment üNonoperative treatment üClosed reduction should be performed after adequate clinical evaluation and appropriate sedation üReduction Techniques: üTraction/countertraction- Generally used with a sheet wrapped around the patient and one wrapped around the reducer. üHippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial traction üStimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be used üMilch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral head üScapular manipulation

Shoulder Dislocations üPostreduction üPost reduction films are a must to confirm the position of the humeral head üPain control üImmobilization for 7 -10 days then begin progressive ROM üOperative Indications üIrreducible shoulder (soft tissue interposition) üDisplaced greater tuberosity fractures üGlenoid rim fractures bigger than 5 mm üElective repair for younger patients

Proximal Humerus Fractures

Proximal Humerus Fractures üEpidemiology üMost common fracture of the humerus üHigher incidence in the elderly, thought to be related to osteoporosis üFemales 2: 1 greater incidence than males üMechanism of Injury üMost commonly a fall onto an outstretched arm from standing height üYounger patient typically present after high energy trauma such as MVA

Proximal Humerus Fractures üClinical Evaluation üPatients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation üCareful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

Proximal Humerus Fractures üNeer Classification üFour parts üGreater and lesser tuberosities, üHumeral shaft üHumeral head üA part is displaced if >1 cm displacement or >45 degrees of angulation is seen

Proximal Humerus Fractures ü Treatment ü Minimally displaced fractures- Sling immobilization, early motion ü Two-part fracturesüAnatomic neck fractures likely require ORIF. High incidence of osteonecrosis üSurgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF ü Three-part fractures üDue to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement requires ORIF. ü Four-part fractures üIn general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13 -34%)

Shoulder Impingment What is it? üRotator cuff impingement syndrome is a clinical diagnosis that is caused by mechanical impingement of the rotator cuff by its surrounding structures. üPatients with impingement syndromes may present with various signs and symptoms on physical examination depending on the degree of pathology and the structures involved.

Shoulder Impingment üSubacromial Impingement üSubcoracoid Impingement üSecondary Extrinsic Impingment üPosterosuperior glenoid impingement üAnterosuperior glenoid impingement

Subacromial Impingement § Narrowing of the space between the humeral head § § § and the coracoacromial arch (supraspinatus outlet); Causing entrapment of the supraspinatus tendon and subacromial bursa. Repeated trauma to these structures will lead to tendon degeneration/tear and bursitis. Patients complain of pain and tenderness over anterior or anterolateral aspect of the shoulder joint.

Subacromial Impingement ü Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal arch.

Subacromial Impingement üStage 1 disease consists of edema and hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under conservative treatment.

Subacromial Impingement ü Stage 2 disease shows progressive inflammatory changes of the rotator cuff tendons and the subacromial-subdeltoid bursa, and can be treated by removing the bursa and dividing the coracoacromial ligament after failed conservative management.

Subacromial Impingement ü Stage 3 disease manifests as partial or complete tears of the rotator cuff and secondary bony changes at the anterior acromion, the greater tuberosity or the acromioclavicular joint.

Subacromial Impingement üAbnormal acromial shape or position üSubacromial enthesophytes üOs acromiale üThickened coracoacromial ligament üAcromioclavicular joint undersurface osteophytes

SLAP LESIONS

Outline üAnatomy of the Glenoid Labrum üFunction of the Labrum üDefinition of SLAP lesions üClassification of SLAP lesions üEtiology of SLAP Lesions üDiagnosis üManagement

Anatomy of the Glenoid Labrum ü Labrum, Capsule, Biceps tendon and Subscapularis muscle are derived from the same embryological cells. ü Labrum is a fibrocartilaginous tissue with sparse elastin fibers. ü Acts as a transition between the hyaline cartilage of the glenoid and the fibrous joint capsule. Inferiorly, the labrum blends with the articular cartilage of the glenoid. ü Funtions as a stabilizing and load-sharing structure and serves as a site for ligamentous attachment.

Glenoid Labrum

Biceps Anchor üBroad origin from the supraglenoid tubercle AND the superior labrum at the 12 o-clock position. üSupraglenoid tubercle is 5 mm medial to the superior edge of the glenoid rim. It has a variable origin, with some reports of 100% origin from the labrum alone.

Relation of Biceps & Labrum

Biceps Anchor Edge of Labrum

Function of the Labrum üSite for Ligamentous attachment. üOrigin of long head of biceps tendon. üIncreases Glenohumeral contact by 25%, thereby contributing to the stability of the joint.

Normal Variations in Superior Labral Morphology Mileski, Snyder, Davidson üTriangular Labrum ü“Bumper” Labrum üMeniscoid Labrum üSub-labral Foramen ü Buford Complex

Biceps Glenoid Cartilage Triangular Labrum

Biceps Hu m er al He ad Glenoid “Bumper” Labrum

Biceps Rim of G len oid rum Lab Meniscoid Labrum

A Normal Variant found in 1. 5% of shoulders. Humeral Head Cord-like Middle Glenohumeral Ligament with apparently deficient labral tissue below it. L MGH Glenoid The Buford Complex

Definition of SLAP lesions üTerm SLAP coined by Snyder et al. üSuperior Labrum Anterior and Posterior the biceps anchor) üRefers to lesions of the superior labrum (to

Classification…. . by Snyder

Additions to Snyder’s 4 types Type 5: SLAP tear that extends to the inferior aspect of the labrum. Type 6: Superior Labral flap. Type 7: SLAP tear that extends into the capsule.

Etiology of SLAP Lesions üThere is controversy regarding the actual mechanism/s resulting in SLAP lesions. Theories include: Primary shoulder instability leading to internal impingement of the labrum. Traction injury from biceps during the deceleration phase of throwing. Traction/twisting injury from biceps during the late cocking phase of throwing (abduction and external rotation) Compression injury from a FOOSH.

Etiology of SLAP Lesions üLikely, each theory has it’s own merit for a given SLAP pattern, as there are biomechanical or clinical studies supporting each one.