🔸 Pain arising from the shoulder
Rotator cuff disorders: rotator cuff tendinopathy,impingement, subacromiaibursitis, rotator cuff teairs
Glenohumeral_disorders: capsulitis("frozen shoulder"), arthritis, infection (rare) Acromioclavicular
disease Traumatic fracture or dislocation
🔸 Pain arising from elsewhere
Referred pain: neck pain, myocardial ischaemia, referred diaphragmaticpaih,lung, pleura Polymyalgia
rheumatica Malignancy: apical lung cancers, metastases
🔸 Red Flags
•History of cancer; symptoms and signs of cancer; unexplained deformity, mass, or swelling:? tumour
•Red skin, fever, systemically unwell:? infection
Shoulder Pain •Trauma, epileptic fit, electric shock; loss of rotation and abnormal shape:? unreduced dislocation
•Trauma, acute disabling pain and significant weakness:? acute rotator cuff tear
•Unexplained significant sensory or motor deficit:? neurological lesion
🔸 Referral Criteria
•Diagnostic uncertainty or red fag criteria summarised in the pr. slide..
•Pain and significant disability lasting more than six months, despite activity modification, physiotherapy
and steroid injections (ifindicated)
•History of instability
•First dislocation-occupation/sport/active
•Severe post-traumatic acromioclavicular pain
🔸One of the most common fractures
causes of shoulder pain
🔹 1) Musculoskeletal: 🔸 Classification
o Middle third - most common (thinnest section)
A-Traumatic (Fx,Dx,Biceps,RCT).
B-Inflammatory (RA,G,...). o Distal third
C-Infectious (TB,Pyogenic)
D-Degenerative (Tendonitis,RCT,Arthritis). Glenohumeral Ligaments:
🔸
o Proximal third
🔸 Image_with AP thorax and 45° AP cephalic tilt
Rule out neurological or vascular compromise;
E- Neoplasm (Bone,Soft tissues). •SGHL pneumothorax in 3%
🔹 2)Neurologic:
A-Peripheral nerves.
•MGHL
•IGHL Complex
- Anterior
1-Root compress (Fx,Dx,Disc - Posterior
disease,Extamed.Tu) - Axillary pouch
2-Brachial plexus (Trauma ,TOS:Cx.
Rib,scalenus anticus, pectralis
minor,Pancoast). Rotator Cuff muscles:
B-CNS -supraspinatus
-infraspinatus
2-Syringomyelia 1-Intramed.Tu.
-subscapularis ACROMIOCLAVICULAR JOINT 🔶
🔸Management of mild AC joint sprains (types I and II):
🔹 3)Vascular: -teres minor
INJURY'S 🔸Ice analgesia
🔶 nonoperative treatment:
A-Arterial:
“The Shoulder Girdle: 🔸Sling 1-3 weeks
🔸 treat the patient with sling for about 7 days followed
1-Embolic
2.Vasospaslic Five bone structures make up seven
basic articulations or joints.
🔸Early ROM as pain permits
🔸Strength exercises after full ROM achieved
Return to sports after pain-free function achieved 🔸patient may develop painful arthritis of the AC joint.
by range of motion exercises.
3.Aneurysm.
•Sternoclavicular Joint
B-Venous: •AC joint
1-Phlebitis. •Glenohumeral joint GH
•Scapulothoracic Joint 🔶
🔸 Management of type III AC joint sprints:
🔹2.Thrombosis.
4)Referred visceral pain:
management 🔸 Initially same as for I and II
A-Cardiac.
B-Gallbladder. 🔸 Referral to ortho advisable within 72 hours
Most authors advocate conservative management
Outcome just as good as surgery, with quicker recovery time
C-Diaphragmatic.
X-RAY
Acute management of severe ACjoint sprains
(types IV, V, VI)
IMPINGMENT AND ROTATOR 🔸
🔸 Ice, analgesia
Management of any complications (type VI associated with
CUFF
• First stage of rotator cuff disease Affact Shoulder and Elbow 🔸
clavicle fxs, rib fxs, and brachial plexus injuries)
🔸Sling/swath
Early referral
milion of individuals
🔹Associated condations:
Hook-shaped
Clavicle Fractures EXAMINATION trauma
Rotator cuff Tears Os acromial
May involve one tendon or more than one Clavicular Fractures
🔹 Machanism of injury
Chronic degenerative tears
Post.capsular contracture
Scapular dyskinesia
Rotator cuff arthropathy
acute avulsion
Iatrogenic injuries
🔹 presentation classfication
Massive ch.Rotator cuff tear
Glenohumeral cartilage destruction
🔹 Definition
Pathologic changes of the
Pain
Over head activity
Sub chondral osteoporosis Impingment Neer sign
rotator cuff tendons
Humeral head collapse
🔹 Cause
NEER impingment test
Hawkins test
🔹 presentation Trauma
🔹
Pain Degenerative impingment: shoulder disease
Subjective weakness
Atrophy of muscle 🔹 Presentation
Pain,overhead activities
SAI: hawkins test :
Forward flexion of the shoulder to 90 degrees
and internal rotation Risk factors for nonunion:
Prominence of humeral head
supraspinatus -displacement and comminution.
🔹Imaging
Cripitus SAI: neer test : RISK FACTORS
pseudoparalysis passive forward flexion >90 auses pain(slight -older female.
-smoker.
🔹Imaging and treatment Radiographs abduction).
X-rays supacromial injection relieves pain associaed
Greater tuberosity reactive changes, acromial with passive forward flexion >90~ ER Management of Clavicular Fractures
sourcil/spur, high-riding humeral head
Arthrogram
🔹
🔹 Ice, analgesics, arm support for all
Referral rule:
🔹
MRI
treatment 🔹 Imaging: 🔹
•Any displaced, non-middle-third fractures
True AP VIEW 🔹Non-displaced fxs: sling; ROM prn comfort
🔹
Displaced middle-third fractures: figure 8 splint
Proximal migration of the humerus •Re-image in 7 days to assure reduction. If not, refer for The glenohumeral joint is the most mobile and most commonly
Hooked acromion shoulder spica cast dislocated major joint. The tremendous range of motion is achieved at the
🔹TREATMENT:
MRI expense of intrinsic skeletal stability. Kazar found that 45% of dislocations
•non operative 🔷
🔹 Conservative treatment: involve the shoulder. 86% of shoulder dislocations were glenohumeral
dislocations.
•Operative (acromioplasty)
🔹
🔹
Most clavicle fractures can be treated without surgery.
Patients with undisplaced clavicle fractures usually heal well.
Shouldel Dislocation:
🔹
🔹
lt is really difficult to reduce and maintain reduction in cavicle fractures.
Healing will occur despite the degree of displacement.
If the fracture is significantly displaced, then there is a higher incidence of nonunion and this displaced
🔹
he vast majority of glenohumeral dislocations fracture can cause significant, persistant weakness and disability even if the fracture heals.
TREATMENT
🔹
are anterior. In Rowe's series, 98% of used for minimally or nondisplaced fractures of the clavicle
🔹
dislocations were anterior and 2% were use a sling or a figure 8 strap.
🔹
posterior. remove the sling and start range of motion in about 4-6 weeks.
🔹 Hippocratic technique 🔹
🔹
The fracture will probably heal and end with a small bump (callus of healing).
sling is not a bad option for treatment.
“Frozen Shoulder”
•The heel of the foot is placed against the
umeral head in the 🔹There is no difference in treating the patient with a sling or a figure 8 strap.
movement of the shoullder and the arm is not a risk factor for nonunion.
🔷
axilla.
🔹
Anterior dislocation
Definition:
Symptomatic limitation of passive motion in a •And longitudinal traction is applied to the arm surgical treatment The vast majority of glenohumeral
•It was predominant 2000 years.
shoulder
Cause: •Traction and leverage
•Less traumatic
🔹
Absolute Indications:
🔹 Open fractures
dislocations are anterior.
In Rowe's series, 98% of dislocations were anterior and 2%
Stiffening ofjoint capsule after inflammation
Symptoms:
🔹 🔹
🔹
Fractures with neurovascular compromise
Polytrauma
FRACTURE OF PROXIMAL
🔹
were posterior.
Many references have discussed the different
pain
progressive
Kocher maneuver
The supine position ,Holding the elbow 🔹 Displaced Neer Type 2 fractures - Non-union rate of 30% if managed non Operatively (Neer; Edwards et al.)
Floating shoulder (combined clavicle & scapula fractures)-although Edwards et al.(2000) have shown good
HUMERUS 🔹
positions of the humeral head in anterior dislocations.
Subcoracoid dis-locations are the most common, followed
mostly atnight
end of its range of motion (ROM).
lasts 1-2years in 90% ofcases
,Externally rotate humerus
Neuroascular complications and humeral
fracures.
🔹symptomatic non-union
outcomes for undisplaced clavicle fractures w/ foating shoulders. by subglenoid, subclavicular and intrathoracic.
Posterior Dislocation
restricted ROM
ER>Abd>IR 🔹 Stimson techniqe 🔹
The relative indication:
🔹 Comminuted fracture (use buttress plate) Direction of Dislocation
The humeral head is seen impacted onto the
posterior rim of the glenoid.
•The patient is positioned prone
• The arm is allowed to hang down. 🔹
🔹
Segmented fracture
Z-type fracture 🔷 Mechanism Of Injury
•10lb of weight
• Some form of relaxation is usually required. 🔹
🔺
Fracture shortening more than 2 cm
Fracture displacement more than 100%
It is better to use a contoured plate!
-95% of the dislocations were classifed as traumatic, it is very
age dependent.
In the younger age groups, athletic injures are common, such
•defect >20-25%
•Latarjet (coracoid transfer) 🔺
1)superrior plate fixation 2)anteroinferior plate fixation.
Intramedullary nail or screw through the clavicle.
as from athletic trauma or a fall, whereas in older persons,
often the result of falls
•Remplissage technique for Hill Sachs defects
🔺
- watch out for migration of this hardware.
🔺 Hook plate can be used in distal fractures.
Small fragment plate fixation with possible CC ligament reconstruction.
-The indirect mechanisms are usually caused by varying
degrees of abduction, extension, and external rotation forces
on the arm. Inferior dislocation is the result of a
-used in very distal fractures. hyperabduction force that levers the proximal
🔹
Hippocratic technique
The heel of the foot is placed against the humeral
🔹
head in the axilla.
🔹 And longitudinal traction is applied to the arm
🔹 It was predominant 2000 years.
🔹Traction and leverage
Less traumatic
🔹
Kocher Maneuve
🔹 The supine position
🔹
🔹
Holding the elbow
Externally rotate humerus
Neurovascular complications and humeral
fractures.
by fatema okoff
PATHOLOGY
Throughout the orthopaedic literature of the 20th
century,there has been discussion about the "essential
lesion" of recurring anterior glenohumeral dislocation,
credited with identifying the importance of detachment of
the labrum and the anterior gleno-humeral capsule from
the anterior rim of the glenoid.
Rotator cuff disorders: rotator cuff tendinopathy,impingement, subacromiaibursitis, rotator cuff teairs
Glenohumeral_disorders: capsulitis("frozen shoulder"), arthritis, infection (rare) Acromioclavicular
disease Traumatic fracture or dislocation
🔸 Pain arising from elsewhere
Referred pain: neck pain, myocardial ischaemia, referred diaphragmaticpaih,lung, pleura Polymyalgia
rheumatica Malignancy: apical lung cancers, metastases
🔸 Red Flags
•History of cancer; symptoms and signs of cancer; unexplained deformity, mass, or swelling:? tumour
•Red skin, fever, systemically unwell:? infection
Shoulder Pain •Trauma, epileptic fit, electric shock; loss of rotation and abnormal shape:? unreduced dislocation
•Trauma, acute disabling pain and significant weakness:? acute rotator cuff tear
•Unexplained significant sensory or motor deficit:? neurological lesion
🔸 Referral Criteria
•Diagnostic uncertainty or red fag criteria summarised in the pr. slide..
•Pain and significant disability lasting more than six months, despite activity modification, physiotherapy
and steroid injections (ifindicated)
•History of instability
•First dislocation-occupation/sport/active
•Severe post-traumatic acromioclavicular pain
🔸One of the most common fractures
causes of shoulder pain
🔹 1) Musculoskeletal: 🔸 Classification
o Middle third - most common (thinnest section)
A-Traumatic (Fx,Dx,Biceps,RCT).
B-Inflammatory (RA,G,...). o Distal third
C-Infectious (TB,Pyogenic)
D-Degenerative (Tendonitis,RCT,Arthritis). Glenohumeral Ligaments:
🔸
o Proximal third
🔸 Image_with AP thorax and 45° AP cephalic tilt
Rule out neurological or vascular compromise;
E- Neoplasm (Bone,Soft tissues). •SGHL pneumothorax in 3%
🔹 2)Neurologic:
A-Peripheral nerves.
•MGHL
•IGHL Complex
- Anterior
1-Root compress (Fx,Dx,Disc - Posterior
disease,Extamed.Tu) - Axillary pouch
2-Brachial plexus (Trauma ,TOS:Cx.
Rib,scalenus anticus, pectralis
minor,Pancoast). Rotator Cuff muscles:
B-CNS -supraspinatus
-infraspinatus
2-Syringomyelia 1-Intramed.Tu.
-subscapularis ACROMIOCLAVICULAR JOINT 🔶
🔸Management of mild AC joint sprains (types I and II):
🔹 3)Vascular: -teres minor
INJURY'S 🔸Ice analgesia
🔶 nonoperative treatment:
A-Arterial:
“The Shoulder Girdle: 🔸Sling 1-3 weeks
🔸 treat the patient with sling for about 7 days followed
1-Embolic
2.Vasospaslic Five bone structures make up seven
basic articulations or joints.
🔸Early ROM as pain permits
🔸Strength exercises after full ROM achieved
Return to sports after pain-free function achieved 🔸patient may develop painful arthritis of the AC joint.
by range of motion exercises.
3.Aneurysm.
•Sternoclavicular Joint
B-Venous: •AC joint
1-Phlebitis. •Glenohumeral joint GH
•Scapulothoracic Joint 🔶
🔸 Management of type III AC joint sprints:
🔹2.Thrombosis.
4)Referred visceral pain:
management 🔸 Initially same as for I and II
A-Cardiac.
B-Gallbladder. 🔸 Referral to ortho advisable within 72 hours
Most authors advocate conservative management
Outcome just as good as surgery, with quicker recovery time
C-Diaphragmatic.
X-RAY
Acute management of severe ACjoint sprains
(types IV, V, VI)
IMPINGMENT AND ROTATOR 🔸
🔸 Ice, analgesia
Management of any complications (type VI associated with
CUFF
• First stage of rotator cuff disease Affact Shoulder and Elbow 🔸
clavicle fxs, rib fxs, and brachial plexus injuries)
🔸Sling/swath
Early referral
milion of individuals
🔹Associated condations:
Hook-shaped
Clavicle Fractures EXAMINATION trauma
Rotator cuff Tears Os acromial
May involve one tendon or more than one Clavicular Fractures
🔹 Machanism of injury
Chronic degenerative tears
Post.capsular contracture
Scapular dyskinesia
Rotator cuff arthropathy
acute avulsion
Iatrogenic injuries
🔹 presentation classfication
Massive ch.Rotator cuff tear
Glenohumeral cartilage destruction
🔹 Definition
Pathologic changes of the
Pain
Over head activity
Sub chondral osteoporosis Impingment Neer sign
rotator cuff tendons
Humeral head collapse
🔹 Cause
NEER impingment test
Hawkins test
🔹 presentation Trauma
🔹
Pain Degenerative impingment: shoulder disease
Subjective weakness
Atrophy of muscle 🔹 Presentation
Pain,overhead activities
SAI: hawkins test :
Forward flexion of the shoulder to 90 degrees
and internal rotation Risk factors for nonunion:
Prominence of humeral head
supraspinatus -displacement and comminution.
🔹Imaging
Cripitus SAI: neer test : RISK FACTORS
pseudoparalysis passive forward flexion >90 auses pain(slight -older female.
-smoker.
🔹Imaging and treatment Radiographs abduction).
X-rays supacromial injection relieves pain associaed
Greater tuberosity reactive changes, acromial with passive forward flexion >90~ ER Management of Clavicular Fractures
sourcil/spur, high-riding humeral head
Arthrogram
🔹
🔹 Ice, analgesics, arm support for all
Referral rule:
🔹
MRI
treatment 🔹 Imaging: 🔹
•Any displaced, non-middle-third fractures
True AP VIEW 🔹Non-displaced fxs: sling; ROM prn comfort
🔹
Displaced middle-third fractures: figure 8 splint
Proximal migration of the humerus •Re-image in 7 days to assure reduction. If not, refer for The glenohumeral joint is the most mobile and most commonly
Hooked acromion shoulder spica cast dislocated major joint. The tremendous range of motion is achieved at the
🔹TREATMENT:
MRI expense of intrinsic skeletal stability. Kazar found that 45% of dislocations
•non operative 🔷
🔹 Conservative treatment: involve the shoulder. 86% of shoulder dislocations were glenohumeral
dislocations.
•Operative (acromioplasty)
🔹
🔹
Most clavicle fractures can be treated without surgery.
Patients with undisplaced clavicle fractures usually heal well.
Shouldel Dislocation:
🔹
🔹
lt is really difficult to reduce and maintain reduction in cavicle fractures.
Healing will occur despite the degree of displacement.
If the fracture is significantly displaced, then there is a higher incidence of nonunion and this displaced
🔹
he vast majority of glenohumeral dislocations fracture can cause significant, persistant weakness and disability even if the fracture heals.
TREATMENT
🔹
are anterior. In Rowe's series, 98% of used for minimally or nondisplaced fractures of the clavicle
🔹
dislocations were anterior and 2% were use a sling or a figure 8 strap.
🔹
posterior. remove the sling and start range of motion in about 4-6 weeks.
🔹 Hippocratic technique 🔹
🔹
The fracture will probably heal and end with a small bump (callus of healing).
sling is not a bad option for treatment.
“Frozen Shoulder”
•The heel of the foot is placed against the
umeral head in the 🔹There is no difference in treating the patient with a sling or a figure 8 strap.
movement of the shoullder and the arm is not a risk factor for nonunion.
🔷
axilla.
🔹
Anterior dislocation
Definition:
Symptomatic limitation of passive motion in a •And longitudinal traction is applied to the arm surgical treatment The vast majority of glenohumeral
•It was predominant 2000 years.
shoulder
Cause: •Traction and leverage
•Less traumatic
🔹
Absolute Indications:
🔹 Open fractures
dislocations are anterior.
In Rowe's series, 98% of dislocations were anterior and 2%
Stiffening ofjoint capsule after inflammation
Symptoms:
🔹 🔹
🔹
Fractures with neurovascular compromise
Polytrauma
FRACTURE OF PROXIMAL
🔹
were posterior.
Many references have discussed the different
pain
progressive
Kocher maneuver
The supine position ,Holding the elbow 🔹 Displaced Neer Type 2 fractures - Non-union rate of 30% if managed non Operatively (Neer; Edwards et al.)
Floating shoulder (combined clavicle & scapula fractures)-although Edwards et al.(2000) have shown good
HUMERUS 🔹
positions of the humeral head in anterior dislocations.
Subcoracoid dis-locations are the most common, followed
mostly atnight
end of its range of motion (ROM).
lasts 1-2years in 90% ofcases
,Externally rotate humerus
Neuroascular complications and humeral
fracures.
🔹symptomatic non-union
outcomes for undisplaced clavicle fractures w/ foating shoulders. by subglenoid, subclavicular and intrathoracic.
Posterior Dislocation
restricted ROM
ER>Abd>IR 🔹 Stimson techniqe 🔹
The relative indication:
🔹 Comminuted fracture (use buttress plate) Direction of Dislocation
The humeral head is seen impacted onto the
posterior rim of the glenoid.
•The patient is positioned prone
• The arm is allowed to hang down. 🔹
🔹
Segmented fracture
Z-type fracture 🔷 Mechanism Of Injury
•10lb of weight
• Some form of relaxation is usually required. 🔹
🔺
Fracture shortening more than 2 cm
Fracture displacement more than 100%
It is better to use a contoured plate!
-95% of the dislocations were classifed as traumatic, it is very
age dependent.
In the younger age groups, athletic injures are common, such
•defect >20-25%
•Latarjet (coracoid transfer) 🔺
1)superrior plate fixation 2)anteroinferior plate fixation.
Intramedullary nail or screw through the clavicle.
as from athletic trauma or a fall, whereas in older persons,
often the result of falls
•Remplissage technique for Hill Sachs defects
🔺
- watch out for migration of this hardware.
🔺 Hook plate can be used in distal fractures.
Small fragment plate fixation with possible CC ligament reconstruction.
-The indirect mechanisms are usually caused by varying
degrees of abduction, extension, and external rotation forces
on the arm. Inferior dislocation is the result of a
-used in very distal fractures. hyperabduction force that levers the proximal
🔹
Hippocratic technique
The heel of the foot is placed against the humeral
🔹
head in the axilla.
🔹 And longitudinal traction is applied to the arm
🔹 It was predominant 2000 years.
🔹Traction and leverage
Less traumatic
🔹
Kocher Maneuve
🔹 The supine position
🔹
🔹
Holding the elbow
Externally rotate humerus
Neurovascular complications and humeral
fractures.
by fatema okoff
PATHOLOGY
Throughout the orthopaedic literature of the 20th
century,there has been discussion about the "essential
lesion" of recurring anterior glenohumeral dislocation,
credited with identifying the importance of detachment of
the labrum and the anterior gleno-humeral capsule from
the anterior rim of the glenoid.
