iNJURIES AROUND SHOULDER

1. Injuries Around The
Shoulder
Dr. ABHISHEK PATHAK
Associate Professor
Department of Orthopaedics
Gandhi Medical College, Bhopal

2. Basic Anatomy Around Shoulder Joint

3. Basic Anatomy Around Shoulder Joint

4. Shoulder
⇒ Glenohumeral (GH)
⇒ Scapulothoracic (ST)
⇒ Acromioclavicular joint (ACJ)
⇒ Sternoclavicular joint (SCJ)
• Elevation of arm 30° (2:1) = 20° GH + 10° ST
• ST movements elevate arm to 65° in absence of GH
movements - “Shrugging mechanism”.

5. Shoulder Anatomy
• Most mobile joint of body
• Glenoid to humeral head ratio is 4:1
• Make shoulder most mobile but relatively unstable joint
• Stability is almost totally dependent upon the synergism of the
musculotendinous units

6. • The muscles and a lack of
restrictive bony or
ligamentous structure give
the shoulder tremendous
range of motion.
• It also makes the
shoulder very
vulnerable to outside
forces

7. Anterior Stabilizers
•Subscapularis Tendon
•Anterior Labrum
•Anterior Capsular Ligaments
•Coraco Humeral, GH, Inferior GH Ligament
•Inferior may be the most important ligament in the
shoulder
•Anterior Synovial pouches and bursae

8. Rotator Cuff Muscles
•Supraspinatus
•Infraspinatus
•Teres Minor
•Subscapularis
SITS

9. Rotator Cuff Muscles-Action
•Supraspinatus – abduction-initial 15 degree

10. Rotator Cuff Muscles-Action
•Infraspinatus - External rotation

11. Rotator Cuff Muscles-Action
•Teres Minor - depression, external rotation, extension

12. Rotator Cuff Muscles- Action
•Subscapularis - internal rotation
• Lift-Off Test • Napolean Test

13. Rotator Cuff Muscles- Action
•Subscapularis - internal rotation
Apleys Scratch test

14. Movements
•Flexion  Extension

15. Abduction Adduction

16. STATIC STABILIZERS
Normal anatomical structures which are constraints to humeral head translation
like ligaments.
DYANAMIC STABILIZERS
Structures whose normal physiological action creates a stabilizing effect like
muscles

17. DISLOCATION OF THE SHOULDER
JOINT
• ANTERIOR
• POSTERIOR
• INFERIOR (LUXATIO ERECTAE)

18. MECHANISM OF INJURY AND CLINICAL
FEATURES OF ANTERIOR
GLENOHUMERAL DISLOCATIONS
• Caused by fall on an outstretched hand
Clinically characterized by
• Shoulder in abduction and external rotation
• Positive Dugas test
• Positive Hamilton ruler test
• Positive Callaway’s test

19. Bryant Test
• Lowering of the Axillary fold in
dislocation of the shoulder

20. Calloways Test
• Increase in Axillary Girth of
shoulder
• Sign for anterior dislocation of
shoulder

21. Dugas Test
• Cross body adduction if patient
not able to perform this
indicates anterior dislocation
shoulder

22. Hamilton Ruler test
• Loss of contour makes lateral
end of acromion to come in line
with lateral edge of arm

23. IMAGING

24. IMAGING

26. TREATMENT
CLOSED REDUCTION
• Hippocrates maneuver
• Kocher’s maneuver
• Stimpson’s method

27. EMERGENT MANAGEMENT OF
ACUTE DISLOCATIONS
Hippocrates
Kocher’s Stimpson’s

28. NON-OPERATIVE TREATMENT PROTOCOL
• All patients< 30 yrs shoulder immobilized for 3 wks
• Patients 30-40yrs shoulder immobilized for 1-2 wks
• Patients >40 yrs the shoulder immobilized for 1 wks

29. Recurrent anterior Shoulder Dislocation
Problem Assessment
• 50% of all major joint dislocation (Anterior-97%)
• Extreme Rotation can make shoulder to pop out
• High chance of recurrence. (14-100%)
• If left untreated can lead to recurrence further leading to
Osteoarthritis

30. Recurrence Rate after First time Anterior
Shoulder Dislocation
0
10
20
30
40
50
60
70
80
90
18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 >35
Recurrence
Rate
Age In Years
Male Female
Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and
risk of recurrent instability after primary traumatic anterior shoulder dislocation in
young patients. J Bone Joint Surg Am.2006;88:2326-2336

31. COMPLICATIONS
• Neurovascular damage
• Recurrence
Age is the single most important factor for developing recurrent
instability.
• Patient <20 yrs.recurrence is > 85%
• Patient > 40 yrs. recurrence is < 6%

32. Bankart Lesion & Hill Sach Lesion

33. OPERATIVE TREATMENT
• PUTTI-PLATT OPERATION
• BANKART REPAIR
Open
Arthroscopic

34. BANKART REPAIR - Arthroscopic

35. FOR RECURRENT ANTERIOR INSTABILITY
• Medially displaced labrum mobilized and reattached to glenoid rim with suture
anchors- ARTHROSCOPIC BANKART PROCEDURE

37. Laterjet Procedure
• Coracoid Transfer procedure
• Most commonly performed surgery for glenoid bone loss
• Increases Glenoid Track
• Dynamic transfer due to conjoint tendon sling
• Acromioclavicular ligament can be used to repair capsulolabral
complex

38. A-C JOINT SEPARATION
Treatment is essentially
conservative
Jone’s strapping

40. FRACTURE OF THE CLAVICLE

41. MECHANISM OF INJURY AND SITE OF
FRACTURE
• DIRECT IMPACT
• INDIRECT IMPACT : Fall on an utstretched hand
SITE OF FRACTURE
• 85% occur at junction of middle and outer thirds
• Lateral and medial end fractures uncommon

42. CONSERVATIVE TREATMENT
• TRIANGULAR SLING
• FIGURE OF 8 BANDAGE
• CUSTOM MADE CLAVICULAR BRACES

43. OPERATIVE TREATMENT
INDICATED IN –
• Lateral end fractures
• Non unions
• Fracture fragments pressing over neurovascular bundle

45. FRACTURES OF THE PROXIMAL
HUMERUS
• More common in elderly patients
• Mechanism of injury is by fall on an outstretched hand or a direct blow

46. NEERS CLASSIFICATION

47. CONSERVATIVE TREATMENT
• ABOUT 80-85% FRACTURES OF THE PROXIMAL HUMERUS CAN BE
TREATED CONSERVATIVELY
• INDICATED IN NEER’S TYPE I AND II
• PATIENTS WITH POOR SURGICAL RISK

48. OPERATIVE TREATMENT
• NEER’S TYPE III AND IV FRACTURES
• FRACTURE DISLOCATIONS
• ASSOCIATED NEUROVASCULAR INJURY

49. Operative t/t :
surgical neck # of humerus fixed by per-cut CCS.