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Shoulder sports related injuries

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Shoulder sports related injuries

  1. 1. Shoulder Sports-Related Injuries What the clinician needs to know Manos Antonogiannakis Orthopaedic Surgeon Director of 3rd Orthopaedic Department Centre for Arthroscopy & Shoulder Surgery Hygeia General Hospital Athens Sports Imaging Course 19 May 2017
  2. 2. Shoulder:a complex unstable joint vulnerable to injury Shoulder injuries: extremely painful, restricting the freedom of movement and function drastically.
  3. 3. Every sport can lead to acute injuries and pain of the shoulder joint or chronic injuries due to overuse Contact Sports, sports with a ball, mountain biking, snowboarding, windsurfing, climbing, horse riding fall shoulder injury
  4. 4. By throwing a ball, the shoulder joint is subject to high loads and accelerations . Due to the repetitive throwing movement, chronic overload and microtrauma occurs. A shoulder joint with a very good mobility has a major advantage for a good throw due to the better acceleration moments, the better throwing force and the higher ball speed. This -high speed- movement of the arm must be every time stabilized from the joint capsule, the ligaments and the surroundings tendons.
  5. 5. 5-8% of all acute injuries affect the shoulder joint Sport injuries more commonly affect male active persons from puberty up to the age of 45.
  6. 6. Correct diagnosis ist important A well-established network of orthopedics, radiologists, physiotherapists and trainers is a major requirement for a efficient medical care. The early and correct diagnosis will lead to the early and correct therapy of the injury.
  7. 7. So what does the clinician want to know
  8. 8. As clinical doctors we know the history and examine the patient We need information from imagining and the radiologist : In order to arrive to a diagnosis In decision making about the type of treatment
  9. 9. The four major clinical entities of the shoulder Instability Stiffness Loss of congruity Loss of power
  10. 10. Most common acute shoulder injuries i. Shoulder traumatic dislocation ii. AC-Joint dislocation Tear of the rotaror cuff i. Rupture of the long head of the biceps tendon ii. SLAP Lesion iii. Fracture of the clavicle, scapula, humerus head Usually caused by direct force or contact with other players
  11. 11. Chronic overload damage i. Rotator cuff tendinopathy ii. Long biceps tendinopathy iii. Impingement syndrome/Bursitis subacromialis iv. GIRD Syndrome v. SLAP Lesion vi. AC Joint Arthritis
  12. 12. X-rays serve to: Confirm the diagnosis: –Dislocated –Reduced with notch (Hill Sachs). Eliminate an associated fracture. –Great tubercle –Hill Sachs –Glenoid bone loss
  13. 13. Field strength : High field strength 1, 1.5, 3 Tesla Low field strength 0.5 Tesla Low field strength : longer time to generate images High signal to noise ratio Surface coils (transmitter and receiver of radiofrequency pulses) that generate Pulse sequences T1-weighted sequence (fat bright,- water , muscle intermediate – fibrous, calcioum dark) T2-weighted sequence(water ,fat bright-muscle intermediete-fibrous, calcioum dark Proton density Gradient echo Fat saturation techniques (supress the signal from fat so that pathology to be more obvious) MRI nomenclature The patient is placed into a magnetic field created by a strong magnet
  14. 14. Benign tumors around the shoulder Primary and metastatic malignant tumors Subtle fractures of the upper part of the humerous or the scapula Sinovial diseases ( osteochondromatosis , PVS) Neuropathies of the peripheral nerves that innervate the muscles of the scapula and the shoulder MRI for other diagnosis Be especially suspicious when the clinical presentation is not familiar
  15. 15. Metastatic disease - Lung cancer Osteoid osteoma
  16. 16. Pancoast tumor
  17. 17. Shoulder traumatic dislocation  Greatest Range of Motion in the body  Motion in all 3 planes of movement  Prone to instability Sacrifices stability for mobility
  18. 18. Routine films ● AP ● Scapular Y view ● Axillary view
  19. 19. True a.p X-Ray
  20. 20. History: degree of violence level of athletic participation number of dislocations age of the patient Clinical examination: generalized joint laxity direction of apprehension
  21. 21.  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation What is Instability?
  22. 22. A patient with some degree of laxity dislocates his shoulder after a minor or major accident The most common presentation
  23. 23. MRI •Best for Soft Tissue Injuries
  24. 24. Conventional MRI provides a good overview of shoulder lesions and anatomy MR arthrography modality of choice to evaluate the labrum. It has the highest sensitivity and specificity But it is invasive and inconvenient for the patient
  25. 25. Anterior shoulder dislocation
  26. 26. Posterior Dislocation Caution!!
  27. 27. Conventional MRI provides a good overview of shoulder lesions and anatomy, particularly the soft-tissue structures. However, it is less accurate than MR arthrography for depiction of small labroligamentous lesions associated with shoulder dislocation. MR arthrography is the imaging modality of choice to evaluate the labrum. It has the highest sensitivity and specificity of all available modalities. But it is invasive and inconvenient for the patient
  28. 28. Glenoid Shape The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  29. 29. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  30. 30. Although a bony bankart and glenoid and humeral bone defects are being depicted on MRI at present CT-scans are better for the quantification of the defects
  31. 31. CT Scan Bony Bankart
  32. 32. What is the critical limit of Glenoid Bone loss? >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  33. 33. Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface Quantification of Glenoid Bone loss
  34. 34. Our practice The percentage of the glenoid defect was evaluated on the en face reconstructed view with the humeral head eliminated Quantification of Glenoid Bone loss
  35. 35. Humeral Bone Defects Hill-Sachs lesion
  36. 36. Engaging Hill Sachs
  37. 37. OP Goal Restoration of the anatomical structure and biomechanical function of the joint to ensure: • stability • normal function, painlessness, normal range of movement • prevention of development of osteoarthritis
  38. 38. AC-Joint dislocation Direct trauma: lateral or laterocranial impact of the shoulder (fall from a bicycle or horse, American Football)
  39. 39. Pain over the AC Joint Painfully limited mobility of the shoulder Clavicle higher in X-Rays than Acromion CAVE: Fracture of Proc. coracoideus
  40. 40. SC-Joint dislocation Rare High energie trauma with potential other life-threatening injuries Anterior > posterior dislocation Posterior dislocation: danger for compression of the trachea, major vessels or mediastinum CT with contrast is recommended
  41. 41. Tear of the rotaror cuff • Dynamic stabilizer of the shoulder • Contributes strength to the arm (50% of the abduction strength is generated by supraspinatus) • Couple forces stabilize and regulate the motion of the shoulder • Internal and external rotation of the shoulder
  42. 42. Natural History of a Tear • Tears DO NOT HEAL • Some but NOT ALL of them will progress • Rot cuff arthropathy is the end stage (4-20%) • 50% of newly symptomatic tears will progress in size • 20% of asymptomatic tears will progress • No Tear decrease in size • 80% of partial tears progress in size or become full thickness in 2 years [Yamaguchi K., 2006, Nice Shoulder Course]
  43. 43. Philosophy of treatment Restore the equilibrium between functional demands and capacity of the rotator cuff  Lower the functional demands of the patient.  Increase the functional capacity of the remaining intact cuff  Repair the cuff Restore the anatomy even partially in an atraumatic way
  44. 44. Prognosis  Dimensions and extent of tear  Condition of the involved tendon (retraction – elasticity)  Tear morphology  Chronicity of tear  Evidence of muscle atrophy, fatty degeneration
  45. 45. Partial Thickness Tears grade Ι : < 25% tendon thickness (< 3mm) grade ΙI : 25-50% tendon thickness (3-6mm) grade ΙII: > 50% tendon thickness (> 6mm) A: Articular B: Bursal C: Intresubstance
  46. 46. Partial Tears Partial tears are better imaged by MR direct arthrography High(fluid) signal intensity due to Gadolinioum through a portion of the tendon Common in young athletes in combination with SLAP tears
  47. 47. Steps in measuring the size of RCT Measure L (medial to lateral length) Measure W (anterior to posterior length)
  48. 48. Complete Tears  Small 1cm  Medium 2-3cm  Large 3-5 cm  Massive >5cm 90-95% excellent in small and medium size tears at 4 to 10 years follow-up Good to excellent results in massive tears with less than 75% fatty infiltration of the Infraspinatus even at 10 years follow-up
  49. 49. Classification Type Description Preoperative MRI Findings Treatment Prognosis 1 Crescent Short and wide tear End-to-bone repair Good to excellent 2 Longitudinal (L or U) Long and narrow tear Margin convergence Good to excellent 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good 4 Cuff tear arthropathy Cuff tear arthropathy Arthroplasty Fair to good.
  50. 50. Preoperative estimation of fatty infiltration of infraspinatus and supraspinatus muscle bellies affects the prognosis
  51. 51. Fatty Infiltration According to Goutallier et al. in CT scan 0 Normal 1 Some fatty streaks 2 More muscle 3 Muscle = Fat 4 More fat
  52. 52. Fatty infiltration
  53. 53. Ruptur of the long head of the biceps tendon Long biceps tendon • length: 10cm • diameter: 5-6 mm • intraarticular fraction • extraarticular fraction intratubercular fraction extratubercular fraction Sliding 2cm in and out of the joint
  54. 54. Anterior pain at the sulcus bicipitalis Distalisation of the muscle belly Loss of force 5%-20% elbow flexion 10-20% forearm supination
  55. 55. Tenotomy vs Tenodesis • Damage/Quality of the tendon • Age of the patient • Activity level • Cosmetic issues • Wish of the patient Young, slim patient with high activity level and cosmetic issues Bad quality of tendon, old patient Tenodesis Tenotomy Decision for tenotomy or tenodesis:
  56. 56. SLAP Lesion Young patients Anterior deep pain of the shoulder O´ Brien Test: + MRI with i.a contrast
  57. 57. SLAP lesions
  58. 58. SLAP - Type I
  59. 59. SLAP - Type II
  60. 60. SLAP - Type III
  61. 61. SLAP - Type IV
  62. 62. Fracture of the clavicle Most common cause: fall on the extended hand Clavicle fractures: 3% of all fractures Clavicular fractures: i) of the middle third: 70% ii) lateral clavicle fractures: 25% iii) medial clavicle fractures: 5%
  63. 63. Conservative therapy i) no additional nerve-, vascular- or major soft tissue injuries ii) Length shortening <15-20 mm iii) Angle of the fracture <20-25 ° Clavicle 8-Brace •so tight that the patient tolerates it •no neurological or venous problems
  64. 64. OP Indication • Vascular or nerve injuries • Open fracture • Tranverse intermediate fragment (poor healing) • Fragment pressure to the skin or danger of skin perforation • ´Floating shoulder´ (ipsilateral clavicle fracture and fracture of the neck of glenoid) • Pathological fractures • Pseudoarthrosis
  65. 65. Fracture of the scapula nearly 1% of all fractures High energie trauma, fall from greater height, shoulder dislocation often associated with other severe injuries such as thorax injuries or clavicle fractures
  66. 66. Fracture of the humerus head 5% of all fractures 70% of all patient with humerus head fracture are older than 60 years old Danger for posttraumatic osteonecrosis due to the reduced vascularisation
  67. 67. Conservative therapy Dislocation of fracture < 1cm Rotation of the humerus head < 45° OP Indication Tuberculum dislocation >5mm (<65 years old) >10mm (<65 years old) Axis Deviation > 45° Intraarticular formation of a gap >2mm
  68. 68. FROZEN SHOULDER when overestimation of MRI reports can lead to clinical mistakes
  69. 69. Frozen Shoulder Thickened coracohumeral ligament Thickening of soft tissue in the rotator interval Thickened inferior glenohumeral ligament
  70. 70. Thank you for your attention
  71. 71. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  72. 72. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment 1 <25% On track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair plus remplissage 3 >25% On track Latarjet procedure 4 >25% Off track Latarjet procedure with or without humeral sided procedure (humeral bone graft or remplissage), depending on engagement of Hill-Sachs lesion after Latarjet procedure
  73. 73. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head The width of the glenoid track without a glenoid defect is 83% of the glenoid width. B. Relation of glenohumeral joint in abduction and external rotation. The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14% of the glenoid width: F - M = 83% of glenoid width = glenoid track.
  74. 74. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A. 3D CT scan with en face view of a glenoid with bone loss of width d. In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d. B. Relation of glenohumeral joint in abduction and external rotation. One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid. In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill- Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.
  75. 75. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart How to Determine Whether Hill-Sachs Lesion Is “On Track” or “Off Track” 1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan 2. Determine the width of the anterior glenoid bone loss (d). 3. Calculate the width of the glenoid track (GT) by the following formula: GT = 0.83 D - d. 4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI=HS + BB. 5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.
  76. 76. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  77. 77. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  78. 78. ●From engaging Hill Sachs to On- track & Off-track lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure What happens in between? It is the combination of the existing lesions Large Hill-Sachs lesion + No glenoid bone loss = Small Hill-Sachs lesion + 15% -20% glenoid bone loss

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