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Shoulder Instability Basics

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Shoulder Instability: An Overview – PowerPoint PPT presentation

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Title: Shoulder Instability Basics


1
Shoulder Instability Basics
  • 18 February 2010

2
Contents
  • Terminology
  • Anatomy
  • Pathophysiology
  • Evaluation
  • Nonoperative Treatment
  • Operative Treatment
  • Treatment Course/Outcomes

3
Terminology
  • Laxity
  • Asymptomatic, passive translation of the humeral
    head on the glenoid unassociated with pain
  • Instability
  • Symptomatic pain/apprehension associated with
    excessive translation of the humeral head during
    active motion

4
Shoulder Anatomy and Function
5
Skeletal Anatomy
6
Skeletal Anatomy
7
Osteology
  • Glenoid version
  • 30o anterior
  • Humerus
  • Neck-shaft 130o to 140o
  • Retrotorsion 30o

8
Superficial Anatomy
9
Rotator Cuff Anatomy
10
GHJ Anatomy
11
GHJ Anatomy (contd)
12
Labrum
  • Fibrocartilaginous ring
  • Anchors capsuloligamentous structures
  • Deepens the glenoid
  • Doubles depth
  • Increases Surface area

13
SGHL
  • Most constant ligament but variable thickness
  • 3 variations of origin
  • Inserts into top of humerus near tip of lesser
    tuberosity

14
Function-SGHL
  • Limit inferior translation and external rotation
    when arm is adducted
  • Limit posterior translation when the arm flexed,
    add, IR

15
Rotator Interval
  • Triangular area of tissue
    from supraspinatus superiorly to subscapularis
    inferiorly
  • Capsule thickened by SGHL CH lig
  • Defects - ?? Significance

16
MGHL
  • Most variable
  • Sheetlike or cordlike
  • Originates from labrum or neck of glenoid just
    inf to SGHL
  • Inserts just medial to lesser tub closely opposed
    to subscap

17
Function
  • Limits anterior translation with 60o to 90o
    abduction and ER
  • Limits inferior translation with
    the arm adducted

18
IGHL
  • Anterior band, axillary pouch, posterior band
  • Originates from labrum/glenoid neck
  • Ant band 2 to 4 oclock
  • Post band 7 to 9 oclock
  • Inserts into anatomic neck humerus 90o arc

19
Function
  • Limits anterior, posterior, and inferior
    translation depending on arm position
  • aIGHL limits AP translation in ext, pIGHL limits
    AP translation in flex

20
Capsuloligamentous Structures
21
Instability Pathophysiology
  • Most motion of any joint
  • Dynamic and Static Restraints
  • Bankart lesion
  • Avulsion of IGHL Labrum complex
  • HAGL

22
Stability
  • Static Factors
  • Articular Congruence
  • Articular Version
  • Glenoid Labrum
  • Capsule and Ligament

23
Pathology-version
  • Glenoid dysplasia
  • 1 to 3 of instability cases
  • Avoid surgery

24
Glenoid Rim Fracture
  • Reduces contact area and glenoid concavity
  • Less than 25 to 33 involvement not a problem if
    IGHL is reattached

25
Hill-Sachs Lesion
  • Impression fracture of posterolateral humeral
    head
  • Little consequence if soft tissue repair is
    performed
  • Some say greater than 30 involvement may lead to
    continued instability

26
Bankart Lesion
  • Detachment of anteroinferior labrum
  • IGHL is key
  • Essential lesion??
  • Speer, et al JBJS 76A, 1994

27
Capsular Injury
  • Acute tears
  • HAGL lesion
  • Plastic deformation
  • Bigliani, et al JORS, 1992
  • Circle concept
  • Need for capsular shift failure of scope repairs

28
Stability
  • Dynamic Factors
  • Rotator Cuff
  • Biceps Tendon
  • Negative Pressure
  • Scapulothoracic motion

29
Rotator Cuff
  • Compression enhances conformity
  • Greater than static stabilizers
  • Coordinated contractions/steering effect
  • Supraspinatus most important
  • Dynamization

30
Scapulothoracic Motion
  • 21 glenohumeral to scapulothoracic motion
  • Scapulothoracic muscle (trapezius, serratus
    anterior) weakness produces winging less
    stable platform

31
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
  • with lax capsule or defect

32
Stability
  • Static Factors
  • Articular Congruence
  • Articular Version
  • Glenoid Labrum
  • Capsule and Ligament
  • Dynamic Factors
  • Rotator Cuff
  • Biceps Tendon
  • Negative Pressure
  • Scapulothoracic motion

33
Instability Categories
  • TUBS
  • Traumatic
  • Unidirectional
  • Bankart lesion
  • Surgery
  • AMBRII
  • Atraumatic
  • Multidirectional
  • Bilateral
  • Rehabilitation
  • Inferior capsule
  • Interval closure

Thomas Matsen, JBJS(1989)
34
Multidirectional Instability
  • Definition
  • symptomatic increased translation of humeral head
    on glenoid.
  • Can be subluxated or dislocated, in three
    directions with reproduced symptoms with one or
    more of these directions.

35
MDI
  • No Single Etiology
  • Inherent Ligamentous Laxity
  • Trauma (Major/Repetitive Minor)
  • Scapular Mechanics

36
A Spectrum
  • Traumatic Microtrauma Atraumatic
  • Less laxity More
    laxity
  • Unidirectional
    Multidirectional

37
Instability
  • Classification
  • Frequency
  • Direction
  • Degree
  • Etiology

38
Classification
  • Frequency
  • Acute
  • Recurrent
  • Fixed (chronic)
  • Cause
  • Traumatic event (macrotrauma)
  • Atraumatic event (voluntary, involuntary)
  • Microtrauma
  • Congenital condition
  • Neuromuscular condition (cerebral palsy, seizures)

39
Instability
  • Patient Evaluation

40
History
  • Position of Instability
  • Traumatic/Atraumatic
  • Onset of Symptomsgt
  • Need for Reduction
  • Psychiatric Component
  • Family History
  • Inf. Instab. pain with carrying
    suitcase/shopping bags _at_ side
  • Ant. Instab. throwing, reaching objects
    ABD/ER
  • Post. Instab. pushing heavy doors FF/IR

41
Anterior Instability
  • Traumatic, acute, dislocation
  • Traumatic, acute, subluxation
  • Recurrent anterior instability
  • Chronic recurrent anterior dislocations
  • Chronic recurrent anterior subluxation
  • Fixed (locked) anterior dislocation

42
Posterior Instability
  • Traumatic acute dislocation
  • Traumatic acute subluxation
  • Recurrent posterior instability
  • Recurrent posterior dislocation
  • Recurrent posterior subluxation
  • Voluntary
  • Positional
  • Muscular
  • Chronic (locked) dislocation
  • lt25 of articular surface
  • 25-40 of articular surface
  • lt40 of articular surface

43
Multidirectional Instability
  • Type I - Global, atraumatic, instability
  • Type II - Anterior/inferior instability
  • Macrotrauma in setting of hyperlaxity
  • Type III - Posterior/inferior instability
  • Microtrauma in setting of hyperlaxity
  • Type IV - Anterior/posterior instability

44
Clinical Evaluation - History
  • Careful history is paramount
  • 1st episode of dislocation or subluxation
  • Degree of trauma - major, trivial, none
  • Dislocation vs. subluxation
  • Position of arm
  • More frequent episodes
  • Treatment

45
History - Present Symptoms
  • Arm slips out
  • Dead arm syndrome
  • Pain
  • Anterior/posterior pain ant/post instability
  • Pain in context of arm position
  • Cocking vs. follow-through
  • Carrying heavy items
  • Secondary impingement
  • Popping/clicking

46
History- contd
  • Functional losses
  • ADLs vs. sports
  • Activity modification
  • Voluntary control
  • Positional
  • Muscular

47
Physical Examination
  • Inspection
  • Palpation/ROM
  • Ligamentous laxity
  • Load-Shift test
  • Apprehension test/ Relocation test
  • Sulcus sign
  • RC pathology

48
Physical Examination
  • Examine both shoulders
  • Cervical spine
  • Generalized ligamentous laxity

49
Generalized Joint Laxity Tests
  • Passive thumb apposition
  • Passive finger hyper-extension so finger
    parallels forearm
  • Elbow hyper-extension gt10 degrees
  • Knee hyper-extension gt10 degrees
  • Excessive ankle dorsiflexion and foot eversion

Carter and Wilkinson in (Brown CORR, 2000)
50
Shoulder Exam
  • Muscular atrophy
  • Tenderness
  • AC and SC joint tenderness
  • ROM - active passive
  • Winging
  • Muscle strength
  • Supraspinatus - 90o scap elevation/45o int rot
  • Infraspinatus - 0o scap elevation/ -45o rot
  • Subscapularis - lift-off/ Napoleans
  • Deltoid/Biceps/triceps/trapezius

51
Anterior Apprehension Test
52
Relocation Test
53
Posterior Apprehension
54
Load and Shift Test
  • Grade I - to the glenoid rim
  • Grade II - Over the rim, spontaneous reduction
  • Grade III - Remains dislocated

55
Sulcus Sign
  • 1 Less than 1 cm
  • 2 1-2 cm
  • 3 Greater than 2 cm
  • Pathognomonic of MDI
  • Neutral vs. ER

56
Imaging Studies
  • Radiographs
  • True AP Glenohumeral joint
  • Trans Scapular Y
  • Axillary
  • West Point axillary
  • Stryker notch view
  • Arthrography
  • CT
  • MRI

57
True AP Scapular Y
58
Axillary and West Point
59
Stryker Notch View
60
Get an Axillary!
61
Computed Tomography
62
Magnetic Resonance Imaging
63
Diagnostic Arthroscopy
64
Arthroscopic Pathology
  • Bankart lesion 80-90
  • Hill-Sachs lesion 80
  • Other signs
  • Labral wear, splitting, blunting
  • Chondral injuries
  • Patulous capsule
  • HAGL lesion
  • SLAP posterior cuff
  • Drive through sign

65
Treatment
66
First Time Dislocation
  • Mechanism
  • Bony Defects
  • Genetics
  • Future goals
  • AGE

67
Nonoperative Treatment
  • Rest/ Brief immobilization
  • NSAIDS
  • Exercise program 6 months minimum, indefinite
    maintenance esp. MDI
  • Resistance exercise
  • Proprioception exercises
  • Rockwood and Burkhead (JBJS 1992) 80
    satisfactory results with atraumatic subluxation

68
Instability- Operative Treatment
69
MDI -Operative Treatment
  • Indications
  • Symptomatic
  • Involuntary
  • Global glenohumeral instability
  • Six month nonoperative exercise compliance

70
MDI -Operative Treatment
  • Contraindications
  • Voluntary dislocation
  • Psychiatric history
  • Neurologic injury (Ax and SS nerves)
  • Glenoid aplasia/hypoplasia

71
Instability Procedures
  • Soft tissue defects
  • Open Inferior Capsular Shift
  • Arthroscopic Capsular Shift
  • Thermal Capsulorrhaphy
  • Bony Defects
  • Humerus
  • Glenoid

72
Postoperative Management
  • Six Weeks Immobilization
  • Progressive Resistance Exercises
  • Go Slowly
  • Repair Failure versus Stiffness

73
Complications
  • Recurrent instability
  • Opposite direction subluxation
  • Poor patient selection

74
Outcomes
75
Open Capsular Shift
  • Altchek and associates (JBJS 1991)
  • Bigliani and associates (AJSM 1994)
  • Bak and associates (AJSM 2000)
  • Pollock and associates (JBJS 2000)

76
Arthroscopic Technique
  • Altchek and assoc. (JBJS 1991)
  • Gartsman and assoc. (Arthroscopy 2001)
  • Nelson and assoc. (AJSM 2000)

77
Thermal Capsulorrhaphy
  • Savoie and assoc. (Arthroscopy 2001)
  • Rotator interval capsule doesnt respond well
    to shrinkage - Plication with sutures

78
Questions??
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