12/10/2016 Disclosures None SNAP, CRACKLE, POP ACUTE SHOULDER - - PowerPoint PPT Presentation

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Nicholas Colyvas MD Orthopedic Surgery and Sports Medicine UCSF

SNAP, CRACKLE, POP

ACUTE SHOULDER TRAUMA

Disclosures

None

Shoulder

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OBJECTIVES

Define the most common acute shoulder trauma issues Discuss the nature of these injuries: history, physical exam and imaging Go through the treatment options

OBJECTIVES

Not comprehensive Will focus on understanding the pathology and rationale of treatment Will try to highlight what to look for as a PCSM physician When to refer to Ortho

Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

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Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

Rotator Cuff Anatomy Shoulder: Rotator Cuff

The rotator cuff is the group of tendons that stabilize the shoulder joint Damage to rotator cuff can be from acute injury or repetitive strains

• Degeneration with aging or

inflammation from tendinitis, bursitis, or arthritis

• Trauma (sports, falling, repetitive
• verhead motions)

ROTATOR CUFF DISEASE

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Presentation

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Older age group, predominantly male May have had some more chronic shoulder symptoms Distinct episode, often associated with a feeling of a pop or tearing sensation Acute loss of function, some swelling and pain A subgroup that does better with surgical treatment- consider early imaging

Rotator cuff tears

Partial RC tears

• First treated conservatively, RC repair if

conservative management fails Full-thickness RC tears

• Severe weakness and limited ROM
• Zipper phenomenon: Generally start in

supraspinatus and progress posteriorly to infraspinatus

• Long head of biceps can rupture secondary

to upward displacement of humeral head since supraspinatus tendon lo longer present as a spacer

• Tear can progress across bicipital groove to

involve subscapularis

• surgery

Surgery: Rotator cuff repair

Chronic tears: Surgery recommended if symptoms of 6-12 months, large tear ≥ 3cm, significant weakness or loss of function, or recent acute injury Acute tears: Operate as soon as possible, therefore have a high degree of suspicion based on history and exam Consider injection/MRI early to facilitate decision making

Rotator cuff repair results/outcomes

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Acute tears do better Smaller tears do better Risk of re-tear Re-tear does not always necessitate more surgery May not recover full function

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Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

BICEPS TENDON

RUPTURE OF THE LONG HEAD OF the BICEPS

BICEPS TENDON two proximal attachments BICEPS TENDON RUPTURE (long head) Presentation

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BICEPS TENDON RUPTURE (long head) Popeye deformity Biceps Rupture

Diagnosis made clinically Obtain an MRI to look at associated Rotator cuff pathology if clinically indicated Not usually surgical, do well with rehab Will lose some supination strength, minimal flexion strength- approx 15% Consider surgery in younger/dominant arm/higher level sports or work

Strength loss

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elbow flexion was diminished by 16%, of supination of the forearm by 11%, and of shoulder abduction by 16%. The patients who underwent surgery lost, on average, only 8% strength for elbow flexion and 7% for forearm supination. Shoulder abduction was decreased by 20%. Arch Orthop Trauma Surg. 1986;105(1):18-23.Muscular strength after rupture of the long head of the biceps. Sturzenegger M, Béguin D, Grünig B, Jakob RP.

• Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

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AC Joint injuries

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Approx 12% of dislocations Males: female ratio 5:1 Common in contact sports Direct blow

Type 1: no surgery

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Type 2: no surgery

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Type 3: somewhat controversial.

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Type 5: Surgery

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Types 4 and 6-rare, surgery

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AC Joint injuries

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Most treated conservatively and will do well Cosmetic deformity Surgery for grade 3 or more Surgery is not without its problems

Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

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Shoulder dislocations

Most common joint to dislocate due to mobility Subluxation: partial dislocation Complete dislocation: Separation of humerus from scapula at glenohumeral joint Anterior dislocations, Posterior dislocations, or Inferior dislocations Over 95% of glenohumeral dislocations are anterior

Anterior dislocations

Bimodal age distribution

• Largest group are young adult men

who sustain high-energy injuries Mechanism

• Violent external rotation in abduction

causes humeral head to leave glenoid socket, damaging soft tissue structures (Bankart lesion)

• As posterior part of humeral head

exits joint, it can collide with anterior rim of glenoid, creating a bony indentation (Hill Sachs lesion)

Presentation Considerations

Bone Injury

• X-ray before reduction r/o humeral

fracture

• Must get an Axillary view: determines

direction of dislocation Vascular injury

• Very rare, older patients have less

elasticity in axillary artery

• Always check NV status before and

after relocation

Presentation considerations

Nerve Injury

• About 10% sustain injury to axillary

nerve

• Brachial plexus injury more unusual
• Always check NV status

Rotator Cuff tears

• Between 14-65% associated with

rotator cuff tears

• Increasing incidence in older patients:
• have a degree of suspicion in older

patients

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Treatment

Reduction

• No consensus on optimum

technique

• Ideally reduced with the patient

relaxed: under regional or even general anesthesia, but in practice initial reduction usually attempted

Treatment

Post-reduction treatment

• Sling with the arm in external rotation for

1-3 weeks

• Physical therapy
• May take up to 3 months to regain function

Recurrent dislocations risk variable with age

• For patients <20, risk up to 95%
• For patients 20-25, risk 50-75%
• Older patients, remember high risk of

rotator cuff tear

After relocation

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XR Ice /NSAIDS period of immobilisation PT

Surgery

Generally for recurrent dislocators Anatomic repairs focus on repairing disrupted structure

• Labral repair

‒ Bankart repair ‒ Posterior labral repair ‒ SLAP repair ‒ Latarjet for recurrent dislocations with bone loss

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Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

Clavicle fractures

Account for approximately 5% of all fractures

• Most common type of

pediatric fracture

• Twice as common in males

Usually a result of acute trauma Most often fractured in the middle third of its length XR

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Clavicle fractures

• Nondisplaced or minimally displaced

fractures treated conservatively

• If necessary, displaced fractures

treated with ORIF

• Surgery Criteria

‒ Complete displacement, bayonetting ‒ Skin tenting ‒ Significant comminution ‒ 2cm shortening ‒ NV compromise

CLAVICLE FRACTURES ORIF Danger ! Distal clavicle fracture

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Acute Shoulder Injuries

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Rotator cuff tears Biceps tendon rupture AC joint Shoulder dislocations / Instability Fractures

• Clavicle
• Proximal humerus

Proximal Humerus Fractures

Account for about 5% of all fractures Common in older patients who from a ground-level fall Higher level of trauma required for young person to sustain injury Complications

• Neurological injury incidence is high

‒ 59% for nondisplaced, 82% for displaced ‒ Axillary nerve most common

• Stiffness

Surgical indications

Displacement of fragment by ≥ 1cm or angulation between fragments ≥ 45 degrees Greater tuberosity should be reduced if displacement ≥ 5 mm Other factors (bone quality, fracture

• rientation, soft tissue injuries, age and health
• f patient) important

2 and 3 part fractures treated with ORIF 4 part fractures treated with ORIF in younger patients, hemiarthroplasty in older patients with osteoporosis

Operative treatment options

Locking Plating Percutaneous Pinning Screw Tension Band Technique

• Screw inserted from shaft up into head
• Figure of 8 tension band wiring passed

around cuff origin on greater tuberosity

• Hole made in humeral shaft
• Second wire inserted through both

tuberosities Shoulder replacement IM nailing

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Examples

A: 2-part fracture, crack in bone between greater tuberosity and humeral head marked with yellow asterisk B: Treatment of 2-part proximal humerus fracture with locking plate. A: 4-part, valgus impacted humerus fracture, can be treated with plate and screws since humeral head in valgus position

• B. Patient treated with fracture

prosthesis

Summary

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Many possible acute injuries to the shoulder Many can be treated non surgically Some need Ortho referral more urgently

Thank You

Nicholas Colyvas MD

Assistant Clinical Professor, UCSF

1500 Owens Street San Francisco CA 94102

Nicholas.Colyvas@ucsf.edu

Questions?