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Fifth stage
Surgery-Ortho
Lec-1
د
.
مثنى
3/1/2016
The Shoulder
Symptoms
Pain; in tip of the shoulder from rotator cuff or acromioclavicular (AC) joint disorders.
Referred pain; from neck (eg. Cervical spondylosis), mediastinum (eg. IHD).
Stiffness (eg frozen shoulder).
Swelling.
Instability.
Weakness; as in neurological disorders or tendon rupture.
Sings
Expose both upper limbs, neck and chest.
Exam from front, behind and axilla.
Look:
o Skin; scar or sinus.
o Shape; swelling, wasting or deformity.
o Position;
Feel:
o Skin: temperature.
o Bone and soft tissue points:
Sternoclavicular joint.
Acromioclavicular joint.
Bicipital groove.
Active movements:
o Abduction: 0-90 degrees glenohumeral movement. Last 60 degrees is
scapulothoracic movement.
o Flexion and extension: raise the arm forwards and backwards.
o Rotation; external (ask the patient to clasp fingers behind the neck), internal
(reach up the back with fingers).
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Disorders of the rotator cuff
The commonest cause of pain around the shoulder.
Rotator cuff anatomy
Consist of tendons of:
o Supraspinatus.
o Infraspinatus.
o Subscapularis.
o Teres minor.
Fused to the capsule of shoulder joint and insert around the greater tuberosity.
Function: Abduction and stabilize the shoulder during movement.
Rotator cuff syndrome is caused by 5 conditions:
Supraspinatus tendinitis (impingement syndrome).
Rupture of the rotator cuff.
Acute calcific tendinitis.
Biceps tendinitis and /or rupture.
Adhesive capsulitis (frozen shoulder).
Impingement syndrome
(supraspinatus tendinitis)
Cause: Repetitive compression or rubbing of the supraspinatus tendon under the
coracoacromial arch during abduction of the arm;
As in painting a wall or cleaning a window.
Other predisposing factors:
o Acromiocalvicular joint OA,
o Gout and rheumatoid arthritis.
Pathogenisis of supraspinatus tendinitis: (wear, tear and repair)
1. Edema and swelling,
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2. Minute tears develop.
3. Scarring, fibrocartilagenous metaplasia or calcification in the tendon.
4. Healing or partial or complete tears.
5. The adjacent tendon of the long head of biceps often involved by tendinitis or tear.
Clinical features
3 clinical patterns:
1. Subacute tendinitis (painful arc syndrome):
Age <40 years.
Anterior shoulder pain after vigorous or unaccustomed activity.
Tenderness over the anterior edge of the acromion.
The painful arc: pain on active abduction of the shoulder between 60 and 120
degrees.
2. Chronic tendinitis
Age 40-50 years.
History of recurrent attacks of subacute tendinitis.
Pain worse at night and on lying on affected side.
Slight stiffness.
Tenderness over the bicipital groove (biceps tendinitis).
3. Cuff disruption (partial or full thickness tear)
Age >45.
History of refractory shoulder pain with increasing stiffness and weakness.
Partial tears; abduction is possible but weak.
Full-thickness tear; abduction of the arm is not possible.
Treatment
Conservative treatment
Uncomplicated impingement syndrome is often self-limiting by eliminating the
aggravating activity.
Avoid impingement position (abduction, slight flexion and internal rotation).
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Physiotherapy; ultrasound and active exercise.
NSAID. If fails,
Local injection of corticosteroid in the subacromial space.
Surgical treatment
Indications:
o Persistent symptoms >3months despite conservative treatment.
o Younger patients with full thickness tear.
Open or arthroscopic acromioplasty.
Repair of rotator cuff tear.
Lesions of the biceps tendon
-Tendinitis:
Usually associated with rotator cuff impingement.
Tenderness over bicipital groove.
Treatment:
o Rest.
o Local heat and massage.
o Corticosteroid injection in the bicipital groove.
Rupture of long head of biceps
Usually accompany rotator cuff disruption.
Age >50.
Snap in the shoulder after lifting an object.
Lump in the lower arm on flexing the elbow.
Treatment; conservative.
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Adhesive capsulitis (Frozen shoulder)
Progressive pain and stiffness of the shoulder which usually resolves spontaneously
after about 18 months.
Cause; unknown.
Pathology: fibroblast proliferation in the joint capsule.
Associated with:
Diabetes mellitus.
Dupuytren’s disease.
Hyperlipidemia.
Hyperthyroidism.
Cardiac disease.
Hemiplegia.
Clinical features
Age: 40-60.
Pain; gradually increasing, disappear within 6 months.
Stiffness; gradually appears as the pain subside, persist for 6-12 months then start
thawing.
Passive and active movement is restricted in all directions.
Treatment
Conservaive: during the painful stage:
Reassurance.
Analgesics and antiinflammatory.
Exersice (pendulum).
After pain subside:
Manipulation under anesthesia with Steroid injection of methyleprednisolone
and lignocaine (risk of fracture neck of humerus in porotic patients).
Surgical release is Indicated for persistent and disabling cases.