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1. The shoulder and pectoral girdle
Dr.Ammr Talib Al-Yassiri
College of Medicine/Baghdad
University

2. Learning outcomes
• Rotator cuff disorders
• Instability of the shoulder
• Disorders of the glenohumeral
joint
• Disorders of the scapula

3. Rotator cuff disorders
• The rotator cuff is made up of the lat.
portions of
– teres minor,
– infraspinatus,
– supraspinatus and
– subscapularis
• contraction of the individual muscles
exerts a rotational pull on the
proximal end of the humerus,
• the main function of the conjoint structure is to draw the
head of the humerus firmly into the glenoid socket and
stabilize it there

4. The commonest cause of pain around the shoulder
‘rotator cuff syndrome’
• supraspinatus impingement syndrome and tendinitis
• Tears of the rotator cuff
• Acute calcific tendinitis
• Adhesive capsulitis (frozen shoulder)
• Biceps tendinitis and/or rupture.

5. IMPINGEMENT SYNDROME, SUPRASPINATUS
TENDINITIS AND CUFF DISRUPTION
PATHOLOGY
• a painful disorder which is thought to arise from repetitive
compression or rubbing of the tendons (mainly supraspinatus)
under the coracoacromial arch.
• The impingement position(abduction, slight flexion and internal
rotation)
• The site of impingement ‘critical area’
• supraspinatus tendinitis may also occur initially in response to
severe repetitive stress
• factors which may predispose to repetitive impingement are
– osteoarthritic thickening of the acromioclavicular joint,
– Swelling of the cuff or the subacromial bursa in inflammatory
disorders such as gout or rheumatoid arthritis.
– Variations of acromial morphology.

8. CLINICAL FEATURES
• pain and/or weakness (over the front and lateral aspect
of the shoulder during activities with the arm abducted
and medially rotated)
• Tenderness
• Three patterns are encountered:
– Subacute tendinitis – the ‘painful arc syndrome’, due to
vascular congestion, microscopic haemorrhage and
oedema.
– Chronic tendinitis – recurrent shoulder pain due to
tendinitis and fibrosis.
– Cuff disruption – recurrent pain, weakness and loss of
movement due to tears in the rotator cuff.

11. IMAGING FOR ROTATOR CUFF DISORDERS:
• X-ray examination
– normal in the early stages
– chronic tendinitis :
• erosion, sclerosis or cyst formation at the site of cuff insertion
• caudal tilt view
• Osteoarthritis of the acromioclavicular joint
– late cases :glenohumeral joint osteoarthritis
• MRI
• Ultrasonography

13. TREATMENT OF CUFF DISORDERS
• Conservative treatment:
– avoiding the ‘impingement position’
– Physiotherapy
– A short course of non-steroidal anti-inflammatory
tablets
– If all these methods fail, the patient should be
given one or two injections of depot corticosteroid
into the subacromial space.
– protective modifications of shoulder activity for at
least 6 months.

14. Surgical treatment
• Indications
– If symptoms do not subside after 3 months of conservative treatment
– if they recur persistently after each period of treatment
– The indication is more pressing if there are signs of a partial rotator cuff
tear and in particular full thickness tear in a younger patient.
• The object is to decompress the rotator cuff
• Repair of the rotator cuff tear if it is indicated
– chronic pain,
– weakness of the shoulder and significant loss of
function.
– The younger and more active the patient, the greater
is the justification for surgery

16. ACUTE CALCIFIC TENDINITIS
• Acute shoulder pain may follow deposition of calcium
hydroxyapatite crystals, usually in the ‘critical zone’ of
the supraspinatus tendon.
• local ischaemia leads to fibrocartilaginous metaplasia
and deposition of crystals by the chondrocytes.
• Clinical features
o 30–50 year-olds
o Aching agonizing climax After a few days, pain
subsides
o During the acute stage the arm is held immobile
o the joint is usually too tender to permit palpation or
movement.

17. • X-RAYS
– Calcification just above the greater tuberosity
• Treatment
– NON-OPERATIVE
TREATMENT
– OPERATIVE
TREATMENT

18. LESIONS OF THE BICEPS TENDON
• Tendenitis
– C/F
• usually occurs together with rotator cuff impingement
• Tenderness
– TREATMENT
• Non operative
• Operative
• Rupture
– C/F
• usually accompanies rotator cuff disruption
• aged over 50
• Snap
• Pain
• Bruise
• Lump
– Treatment

19. ADHESIVE CAPSULITIS (FROZEN
SHOULDER)
• progressive pain and stiffness of the shoulder which usually
resolves spontaneously after about 18 months.
• The histological features are reminiscent of Dupuytren’s disease
• active fibroblastic proliferation in the rotator interval, anterior
capsule and coraco-humeral ligament.
• The condition is particularly associated with
– diabetes,
– Dupuytren’s disease,
– hyperlipidaemia,
– hyperthyroidism,
– cardiac disease
– hemiplegia.
– It occasionally appears after recovery from neurosurgery

20. Clinical features
• aged 40–60
• history of trauma
• aching in the arm and shoulder
• stiffness, untreated stiffness persists for another
6-12 months
• slight wasting
• tenderness is seldom marked
• cardinal features is stubborn lack of movements
in all directions.
• X-rays are normal

22. • Differential dignosis:
– Infection.
– Post-traumatic stiffness
– Diffuse stiffness
– Reflex sympathetic dystrophy
• Treatment
– CONSERVATIVE TREATMENT
• analgesics and anti-inflammatory
• ‘pendulum’ exercises
• reassure
• Manipulation under general anaesthesia +injection with
methylprednisolone and lignocaine
• injecting a large volume (50–200 mL) of sterile saline under pressure
– SURGICAL TREATMENT: Arthroscopic capsular release

23. INSTABILITY OF THE SHOULDER
• The shoulder achieves its uniquely wide range of
movement at the cost of stability
• Pathogenetic classification
shoulders become unstable because one of:
• structural changes
• unbalanced muscle recruitment
Three polar types of disorder can be identified:
– Type I Traumatic structural instability.
– Type II Atraumatic (or minimally traumatic) structural
instability.
– Type III Atraumatic non-structural instability (muscular
dyskinesia)

24. TRAUMATIC ANTERIOR INSTABILITY– POLAR
TYPE I
PATHOLOGY
• commonest type (over 95 per cent)
• usually follows an acute injury
1. the classic Bankart lesion
2. the Hill–Sachs lesion
3. In other cases the labral tear and bone defect
may be absent, althuogh the inferior gleno-
humeral ligament will be stretched
4. In patients over the age of 50, dislocation is
often associated with tears of the rotator cuff.

25. Clinical features
• young man or woman who gives a history of the
shoulder ‘coming out’
• recurrent dislocation requiring treatment develops in
about one-third of patients under the age of 30 and in
about 20 per cent of older patients.
• Recurrent subluxation a ‘catching’ sensation, followed
by ‘numbness’ or ‘weakness’- the so called‘dead arm
syndrome’ whenever the shoulder is used with the arm
in the overhead position
• On examination
– apprehension test

26. Imaging
• x-ray: The Hill–Sachs lesion (when it ispresent)
is best shown by an anteroposterior x-ray with
the shoulder internally rotated, or in the
axillary view. Subluxation is seen in the axillary
view.
• MRI or MR arthrography: bone
lesions and labral tears.

27. Treatment
• If dislocation recurs at long intervals, the
patient may choose to put up with the
inconvenience and simply try to avoid
vulnerable positions of the shoulder.
• OPERATIVE TREATMENT
– indications
• frequent dislocation, especially if this is painful,
• recurrent subluxation or a fear of dislocation sufficient
to prevent participation in everyday activities, including
sport.

28. • Two types of operation are employed:
• Anatomical repairs
– Bankart procedure.
• Non-anatomical repairs
– Putti–Platt operation
– Bristow–Laterjet operation
– Kronberg and Brostrum

29. ATRAUMATIC OR MINIMALLY TRAUMATIC
INSTABILITY – POLAR
TYPES II AND III
include entities such as the ‘loose shoulder’, multidirectional
instability, voluntary dislocation and habitual dislocation
ATRAUMATIC STRUCTURAL INSTABILITY
• acquired multidirectional instability
• due either to
– repetitive micro-trauma which has placed undue stress upon
the soft tissues
– or to rapid, forceful movements that contribute to the
development of overall laxity of the joint;
– occasionally a predisposing factor such as glenoid dysplasia is
identified.
• dislocation may occur in several different directions.

30. • Treatment
– REHABILITATIVE MEASURES Dedicated
physiotherapy is focused on strengthening the
muscles.
– SURGICAL TREATMENT usually some type of
capsular plication (which can be performed
arthroscopically) or a capsular shift (by open
operation).

31. ATRAUMATIC NON-STRUCTURAL INSTABILITY (ALTERED
MUSCLE PATTERNING)
• Each of the muscles moving and stabilizing the
shoulder needs to be activated at a specific time in
coordination with other protagonistic and antagonistic
muscles. If this pattern is altered instability can occur.
• Muscle patterning instability usually occurs in younger
patients who can voluntarily slip the shoulder out of
joint as a trick movement (habitual),
• Treatment follows much the same lines as for
atraumatic structural instability but surgery should be
avoided if possible.

32. POSTERIOR INSTABILITY
• Almost always a posterior subluxation
• C/F:
– takes the form of subluxation when the arm is used in flexion and
internal rotation.
– On examination,
• the posterior drawer test
• posterior apprehension test
• TREATMENT
– physiotherapy.
– SURGERY : should be considered only if the primary abnormality is found to be
structural
• TYPES OF OPERATIONS:
1) Soft-tissue reconstructions are the mainstay of treatment.
2) Rarely glenoid osteotomy
3) In extreme cases a bony block to posterior translation of the humeral
head is employed.

33. DISORDERS OF THE GLENOHUMERAL
JOINT
TUBERCULOSIS
• Uncommon
• starts as an osteitis but is rarely diagnosed until arthritis has supervened. This may
proceed to abscess and sinus formation, but in some cases the tendency is to
fibrosis and ankylosis.
• Clinical features:
– Adults are mainly affected.
– Constant ache and stiffness lasting many months or years.
– The striking feature is wasting of the muscles around the shoulder, especially the
deltoid.
– In neglected cases a sinus may be present over the shoulder or in the
axilla.
– All movements are limited and painful.
– X-rays show generalized rarefaction, usually with some erosion of the joint surfaces
• Treatment: systemic treatment with antituberculous drugs, rest, If there are
repeated flares, or if the articular surfaces are extensively destroyed, the joint
should be arthrodesed.

34. RHEUMATOID ARTHRITIS
• Most common arthropathy to affect the
shoulder complex (90% of rheumatoid pt.)
• Pathology
– The acromioclavicular joint : erosive arthritis
– The gleno-humeral joint: synovitis, cartilage
destruction and bone erosion
– The subacromial bursa and the synovial sheath of
the long head of biceps become inflamed and
thickened; often this leads to rupture of the
rotator cuff and the biceps tendon.

35. • C/F:
– generalized rheumatoid arthritis;
– Pain and swelling;
– the patient (usually a woman) increasing difficulty with simple tasks such as
combing her hair or washing her back.
– synovitis→ swelling and tenderness anteriorly, superiorly or in the axilla.
– Tenosynovitis→features similar to those of cuff lesions
– weakness and limitation of movement
• Treatment:
– general treatment of rheumatoid arthritis.
– local treatment in the form of intra-articular injections of
methylprednisolone
– If synovitis persists, operative synovectomy is carried out; at the same
time, cuff tears may be repaired.
– Excision of the lateral end of the clavicle may relieve acromioclavicular
pain.
– total joint replacement with an unconstrained prosthesis
– arthrodesis

36. OSTEOARTHRITIS
• usually secondary
• Often chondrocalcinosis is present
• (‘Milwaukee shoulder’).
• Clinical features:
– aged 50–60
– history of injury, shoulder dislocation or a previous painful arc
syndrome.
– movements are restricted in all directions.
• X-rays
• Treatment:
– Analgesics and anti-inflammatory
– exercises may improve mobility.
– In advanced cases arthroplasty is justified
– alternative is arthrodesis.

37. DISORDERS OF THE SCAPULA
CONGENITAL ELEVATION OF THE SCAPULA
• complete their descent from the neck by the
third month of fetal life;
• CLINICAL FEATURES
– Sprengel’s deformity
– Klippel–Feil syndrome
• TREATMENT :
– Mild cases are best left untreated.
– Surgical treatment aims to decrease deformity and
improve shoulder function.

38. SCAPULAR INSTABILITY
• Winging of the scapula is due to weakness of the serratus
anterior muscle.
• There are several causes of weakness or paralysis of the
serratus anterior muscle:
– Neuralgic amyotrophy
– Injury to the brachial plexus
– Direct damage to the long thoracic nerve (e.g. during radical
mastectomy)
– fascioscapulohumeral muscular dystrophy.
• Treatment: Disability is usually slight and is best accepted.
However, if function is noticeably impaired, tendon
transfer; or the scapula can be fixed to the rib-cage

40. references
• Apley’s System of Orthopaedics and Fractures
• Review of Orthopedics, Miller
• Campbell’s operative orthopaedics