Shoulder joint
Shoulder joint consist of 5 joints : 1- sterno- clavicular 2- acromio- clavicular, 3- thoraco- scapular 4- subacromial 5- gleno- humeral (proper shoulder)Examination
Symptoms: pain. stiffness. Deformity. loss of function. Signs: 1- look = skin ,shape, position. 2- feel= skin, soft tissues and bony point. 3- move = active movement, passive movement, and power.The patient should always be examined from the front and from the behind. Both upper limbs and the chest must be visible. Examination of the shoulder must include a full examination of the neck .
Imaging : x-ray. arthrography. US. CT. MRI. Arthroscopy.
Shoulder deformitiesCongenital elevation of the scapula (sprengel’s shoulder): result from failure of descend of scapula, painless, associated with other anomalies of spine. Sever type need surgical treatment.
Klippel-Feil syndrome: bilateral failure of scapular descend.
Winged scapularesult from injury of serratus anterior or its nerve supply long thoracic nerve.
Painful shoulder
1--Referred pain cervical spondylosis mediastinal pathology cardiac ischemia 2--Rotator cuff disorders tendinitis rupture frozen shoulder
Painful shoulder
3-- joints disorders glenohumeral arthritis acromioclavicular arthritis 4-- bone lesions infection tumorsPainful shoulder
5-- instability dislocation subluxation 6-- nerve injury suprascapular nerve entrapment.Infection: pyogenic arthritis tuberculosis. Rheumatoid arthritis: shoulder joints are frequently involved in RA.
OSTEOARTHRITS: is usually secondary. OA.of acromioclavicular is common in old patients. Avascular necrosis. Is rare
Rotator cuff disorders
Rotator cuff is conjoint tendon of subscapularis, supraspinatus, infraspinatus, and ters minor fused with shoulder capsule. It is main shoulder stabilizer. The arch above cuff consist of acromion, coracoacromial ligament, and coracoid process. The subacromial bursa separate these two structures. Under the arch and during abduction, the cuff may be irritated or damaged as it glides in confined space.Pathology of rotator cuff lesions
The basic pathological processes degeneration:- the cuff degenerate with age, especially in critical zone 1-2 cm from the insertion (minor tear, scaring, metaplasia, calcification). Trauma:- tear occur with some movement, it may be partial cause impingement or complete tear.Reaction: - in attempt to repair the tear, new blood vessels grow and calcium deposit resorbed and this cause sever pain. In young age the repair is vigorous and rapid but this cause sever pain ( acute tendinitis). In old age the wear is more and repair slower but pain less sever.(chronic tendinitis)
Acute tendinitis ( acute calcification)
Calcium hydroxyapatite deposits critical zone of cuff. When vascular reaction and swelling occur it become painful patient usually young adult develop shoulder pain after overuse. The pain increased gradually to very sever grade. The arm held immobile and joint is tender. After few day the pain gradually decreased.Acute tendinitis ( acute calcification)
X-ray show deposit of calcification above greater tuberosity. Treatment :- rest, analgesia and anti-inflammatory drugs, local steroid injection indicated in sever cases . Surgical removal of calcification for persistent condition.Chronic tendinitis (Painful arc) or( impingement) syndrome overuse and degeneration initiate chronic vascular response. The impingement of rotator cuff against the coracoacromial arch may play part in this process. Patient usually 40-60 years old complain of shoulder pain, increased in night and certain movement. Tenderness felt over shoulder.
On abduction pain aggravated as the arm traverse an arc between 60-120 degree. Crepitus may elicited indicate partial tear. Wasting of muscles may seen.. X-ray shows calcification with upward sublaxation of humeral head and osteoarthritis. MRI show cuff changes. Some patients improve with rest and anti-inflammatory drugs. Steroid injection can used if symptom persist. Surgery used in some cases by decompress the rotator cuff.
Rotator cuff tear
Partial tear of cuff are common precipitate by degeneration. Complete tear follow sudden strain or as complication of partial tear. The patient is adult or old age develop pain in shoulder and inability to lift the arm following strain or fall. Partial tear cause painful arc syndrome. local tenderness or muscle wasting may seen.Rotator cuff tear
Abduction either painful or limited. To distinguish between partial and complete tear local xylocaine injected, if active abduction is now possible the tear is partial. Drop arm occur when the arm lowered from sideways position in complete tear. MRI , US, Arthroscopy confirm the diagnosis. Treatment in acute phase is conservative. After three weeks: in complete tear in young and active patients surgical repair done. In partial tear and tear in old and sedentary patients treated conservatively.Frozen shoulder ( adhesive capsulitis)
Well define disorder characterized by progressive pain and stiffness which resolve spontaneously in about 18- 36 months. The entire cuff and joint capsule affected by chronic inflammatory infiltration. Patient aged 40-60 give history of mild trauma followed by pain increased gradually. After months the pain start to subside and stiffness become more and more. Stiffness persist for 6-12 months. Gradually the movement regained and recovery usually uncompleted. On examination their is stiffness.