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Shoulder and ankle instability
- 1. Jarrad Stevens Orthopaedic Surgeon drstevens@vbjs.com.aiu ShoulderInstability and Ankle Injuries Dave Slattery Orthopaedic Surgeon drslattery@vbjs.com.au
- 2. Shoulder Stabilisers • ShoulderROM due to 4 articulations - GH, ST, AC and SC • Movement mainly from GH and ST - Abduction approx 2:1 = GH:ST motion • Humerus: Retroverted 30° • Glenoid: Retroverted 7° STABILITY: • Static and Dynamic stabilisers • “Concavity - Compression” • “Suction Cup” ANATOMY:
- 3. Shoulder Stabilisers STABILITY: • Glenoidshape • Cartilage thicker on periphery • Glenoid deepened by labrum • GH ligaments and capsule • These are “check reins” at extremes of movement DYNAMIC STABILISERS (Compressors): • Rotator cuff muscles • Deltoid • LHBT – esp against ER in abduction (eg. throwing) STATIC STABILISERS
- 4. Instability Classification Chronicity • Acute,chronic, acute on chronic Direction • Anterior, posterior inferior, MDI Voluntary vs Involuntary
- 5. Instability Classification TUBS • Traumatic •Unilateral • Bankart Lesion • = Surgery AMBRI • Atraumatic • Multidirection • Bilateral • Rehab • Inferior Capsular Shift
- 6. Associated Lesions Bankart Lesion •Antero-inferior capsulolabral complex = • Ant-inf GH ligament • Ant-inf labrum • Inferior capsule • Avulsion of Bone = Bony Bankart Hill-Sachs Lesion • Hill-Sachs lesion – 1940 • Postero-lateral humeral head defect as it impacts on the antero-inferior glenoid rim • 40-90% of primary dislocations • Up to 100% in recurrent dislocators
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- 8. Associated Lesions HAGL • Humeralavulsion of Glenohumeral ligament • Bankart, but off the humeral side Rotator cuff tears • Rare <20 years of age • 30% >40 yo, 80% >60 yo Vascular injury • esp. beware if chronic anterior dislocation Neurological injury • Axillary nerve passing through quadrangular space
- 9. Typical Presentations Anterior • ER,abducted and extended, then force displaces head anteriorly Posterior • axial loading of the IR, Adducted shoulder OR • violent muscle contraction (eg. seizure/electric shock) due to powerful IRs overcoming weak ERs Inferior • Hyperabduction = luxatio erecta David@melbourneboneandjoint.com
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- 14. Clinical Examination Ligamentous Laxity •Wynne Davies or Beighton
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- 25. Reduction Moves >200 Described •Whatever works, without causing more damage!
- 26. Reduction Moves >200 Described •Whatever works, without causing more damage! • Milch/Stimson/Traction-countertraction
- 27. Reduction Moves Contra-indications toReduction • Humeral neck fractures • Suspected major vessel injury • Major nerve injury • Chronic dislocation >48hrs
- 28. Post Reduction Treatment •Confirmation of Reduction • Immobilisation 1-2/52 – ideally in ER to tighten S/Scap and reduce bankart lesion • Aim: • Restoring function • Decreasing risk of recurrence • After immobilisation period, begin RC and scapular stability exercises to increase concavity-compression • Further treatment depends upon risk profile and imaging – CT/MRI
- 29. 1st Time Dislocator- Controversies • Given reported high risk of recurrence (up to 92% in active patients) should primary surgical stabilisation be taking place? • No clear answer at present, consider if other factors • Large HS lesion • Significant bony bankart ?% • Persistent displacement of GT # • Subsequent participation in contact sports • Job requires absolute stability
- 30. 1st Time Dislocator- Controversies
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- 32. WARNING: CONTAINS SURGICAL IMAGESTHAT SOME VIEWERS MAY FIND
- 33. WARNING: CONTAINS SURGICAL IMAGESTHAT SOME VIEWERS MAY FIND
- 34. • 25% ofall musculoskeletal injuries • 20,000 patients seen each day in the US • ATFL injured in isolation 50% cases • ATFL + CFL 25% cases • Isolated AITFL in <5% cases Ankle Sprains
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- 37. Ankle Sprains History • Female/breastfeeding/pregnant •Generalised ligamentous laxity • Cavovarus deformity • Neurological disorders • Mechanism of injury
- 38. Ankle Sprains Exam • Alignmentof hindfoot • Swelling/bruising pattern • Point tenderness • Range of motion • Subtalar joint irritability • Generalised ligamentous laxity • Anterior drawer testing • Syndesmosis stress testing • Neurovascular status
- 39. Ankle Sprains Imaging • X-rays– AP, lateral, oblique weight bearing • MRI • Ultrasound unhelpful
- 40. Ankle Sprains Management • Earlymobilisation and rehabilitation with an experienced physiotherapist • Avoid prolonged non weight bearing
- 41. Ankle Sprains When toREFER: • Symptomatic after 3 months of non-operative treatment • Intensive rehabilitation • Compliance • Functional instability • Recurrence • Ligamentous laxity • Peroneal tendon instability • Subtle cavovarus foot
- 42. Ankle Sprains When toREFER: • Symptomatic after 3 months of non-operative treatment • Intensive rehabilitation • Compliance • Functional instability • Recurrence • Ligamentous laxity • Peroneal tendon instability • Subtle cavovarus foot
- 43. Ankle Sprains Why notSettling: • Chronic instability: – Microinstability – Gross instability • Cavovarus foot • Misdiagnosis • Concomitant injuries
- 44. Ankle Sprains Surgical Mx: •Gold standard: anatomic reconstruction: – Restore ligaments – Restore biomechanics • Brostrom-type reconstruction – ATFL imbrication and re- attachment • Reinforce with internal brace device in some patients
- 45. • Isolated MedialMalleolar • Isolated Lateral Malleolar • Isolated Posterior Malleolar • Bimalleolar • Trimalleolar • Syndesmotic Injuries • Dislocations • Plafond/pilon Ankle Fractures
- 46. • Unimalleoli: 70% •Bilmalleolar: 20% • Trimalleolar: 7% • Open: 3% Incidence
- 47. • Cast ifundisplaced with no talar shift • Fix if displaced • Check the knee x-ray Isolated Medial
- 48. Lateral Type A: Fractureof the fibula below the level of the syndesmosis Type B: Fracture of the fibula at the level of the syndesmosis Type C: Fracture of the fibula above the level of the syndesmosis Affects joint in all planes Interosseous disruption Often associated with posterior fracture
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- 50. • Below thelevel of syndesmosis • Generally treat in plaster or CAM 6/52 FWB Weber A
- 51. • At thelevel of syndesmosis • ORIF if any talar shift or displacement >2mm • ORIF is medial structures not intact (functional bimalleolar fracture) • Lag screw fixation with neutralising plate Weber B
- 52. Weber B • Randomisedpatients to closed contact casting and ORIF • PTs >60yrs • 10% wound complication with ORIF • 15% malunion rate with CCC
- 53. • Have highestincidence of complete syndesmotic injury • Plate if fracture in distal third of fibula • If higher may only require screws if maisonneuve type injury Weber C
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- 55. • >25% jointinvolvement • >2mm step • Must use CT to determine as radiographs inaccurate • CRIF with AP or PA cannulated screw • Posterior plate Posterior Malleolus
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- 57. • Any displacementin Bimalleolar and trimalleolar fractures ORIF • What about ‘functional bimalleolar’ fracture that is Weber B and Deltoid rupture: – examination has been shown to be largely unreliable in predicting medial injury – not necessary to repair medial deltoid ligament – only need to explore medially if you are unable to reduce the mortise Bimalleolar
- 58. • Assessing thesyndesmosis radiographically Syndesmosis
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- 67. Fracture Dislocation • Principlesin Management – Early reduction and stabilisation – Cast / ex-fix or ORIF if swelling appropriate (usually <6hours or >6 days)
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- 74. Diabetic Ankle Injuries •Decision making algorithm the same • But 6% amputation risk due to infection and none union • Rigid fixation • Sutures in twice as long • NWB twice as long
- 80. Intra-Articular Injuries • Pilon= Plafond • High energy axial load • 75% have associated fibula fractures
- 81. Classical Fragments • Pilon= Plafond • High energy axial load • 75% have associated fibula fractures • 3 Fragments: – Volkmann – posterolateral – Chaput – anterolateral – Medial
- 82. Treatment • Safe toapply temporising spanning ex-fix • Leave until swelling resolved approx 14 days • Investigate with CT
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- 85. Treatment • Safe toapply temporising spanning ex-fix • Leave until swelling resolved approx 14 days • Investigate with CT
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- 89. Outcomes • Want tofix fracture to allow: – Early ROM – Early weight bearing – Restoration of muscle – Prevention of secondary complications • High rates of metal problems • High rates of post traumatic OA
- 90. Outcomes • Want tofix fracture to allow: – Early ROM – Early weight bearing – Restoration of muscle – Prevention of secondary complications • High rates of metal problems • High rates of post traumatic OA