Orthopedic surgery

بسم الله الرحمن الرحيم

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The shoulder 'joint' in fact comprises three components-

the gleno-humeral joint or

shoulder joint proper,

acromio-clavicular joint,
and
the sterno-clavicular





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SYMPTOMS

Pain
Stiffness
Deformity
Swelling
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How to Start

• IPEEP
• INTRODUCE.
• PERMISSION.
• EXPLANTION.
• EXPOSURE.
• POSITION.

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The Apley System

All joint examinations follow this system:
Look
Feel
Move : Active then Passive
Special Tests
Radiograpgy.


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Radiographic Anatomy

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Inspection

Bone contours and alignment

Soft-tissue contours

Colour and texture of skin
Scars or sin uses





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Inspection(look)
Front & back

Height of shoulder and scapulae

Muscle atrophy,

asymmetry

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Palpation

Skin temperature
Bone contours
Soft-tissue contours
Local tenderness



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Palpation
Surface Anatomy (Anterior)

Clavicle

SC Joint
Acromion process
AC Joint
Deltoid
Coracoid process
Pectoralis major
Trapezius
Biceps (long head)

AC joint

SC joint

biceps

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Palpation
Surface Anatomy (Posterior)

Scapular spine

Acromion process
Supraspinatus
Infraspinatus
Deltoid
Trapezius
Latissumus dorsi
Scapula
Inferior angle
Medial border

Supraspinatus

Infraspinatus

Inferior angle of scapula

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Movements
Distinguish between gleno-humeral Movement
and
Scapular movement during
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abduction,

flexion,
extension,
lateral rotation,
and medial rotation

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Pain on movement

? Muscle spasm
? Crepitation on movement

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Range of Motion

Forward flexion:
160 - 180°


Extension: 40 - 60°

Abduction: 180◦

Adduction: 45 °

Internal rotation:

60 - 90 °

External rotation:

80 - 90 °

Apley Scratch Test

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Power
Cervico-scapular and thoraco-scapular
muscles
(controlling scapular movement)-
Elevation of scapula,
retraction of scapula,
abduction-
rotation of scapula.
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Scapular dyskinesis (Scapulothoracic dysfuntion)

Compare scapular motion through ROM on both sides

Wall push-ups

Symmetrical
Smooth
No or minimal winging





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S capulo-humeral muscles (controlling

movement at gleno-humeral joint)
-Abduction, adduction,
flexion, extension,
lateral rotation,
medial rotation

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Acromio-clavicular joint

Examine for swelling,
increased
warmth, tenderness,
movement, and stability
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Sterno-clavicular joint

Examine for swelling,


increased warmth, tenderness,
Movement.

and stability

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Grade strength on 0 → 5 scale

0: no contraction
1: muscle flicker; no movement
2: motion, but not against gravity
3: motion against gravity, but not resistance
4: motion against resistance
5: normal strength

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Strength Testing

External rotation

Tests RTC muscles that ER the shoulder

Infraspinatus
Teres minor


Arms at the sides

Elbows flexed to 90 degrees

Externally rotates arms against resistance




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Strength Testing

Internal rotation

Tests RTC muscle that IR the shoulder

Subscapularis

Arms at the sides

Elbows flexed to 90 degrees
Internally rotates arms against resistance


Subscapularis Lift-Off Test

Other techniques

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Strength Testing

Supraspinatus

“Empty can" test

Jobe’s Test

Tests Supraspinatus

Attempt to isolate from deltoid

Positioned sitting

Arms straight out
Elbows locked straight
Thumbs down
Arm at 30 degrees
(in scapular plane)
Attempts to elevate arms against resistance







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SENSORY EXAMINATION

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Impingement Signs

Hawkins

Neer
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Speed’s TestBiceps Tendinopathy
Long head of biceps tendonitis
Fwd flex to 90°, abd 10°, full supination
Apply downward force to distal arm
Pain = (+) test
weakness w/o pain = muscle weakness or rupture


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Sulcus Sign

Inferior instability
Arm relaxed in neutral position, pull downward at elbow
(+) test = sulcus at infra-acromial area
compare to unaffected side


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Instability: Apprehension Test

Anterior instability


Shoulder abducted to 90°
Slight stress to humeral head directed in anterior direction
While externally rotating shoulder

Positive test is apprehension due to feeling of instability or impending dislocation

Beware if false positives




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Drop Arm TestSuggestive of Rotator Cuff Tear

Passive abduction to 90°
Instruct patient to slowly lower arm
At 90° abducted arm will suddenly drop, may need to add slight pressure
(+) drop = (+) test


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Cross-Arm Adduction Test
AC joint pathology
Arm flexed to 90°
Hyperadduct arm across body as far as possible
Pain in AC = (+) test


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EXAMINATION OF POTENTIAL EXTRINSIC SOURCESOF SHOULDER SYMPTOMS

The investigation should include:
I) the neck,with the brachial plexus;
2) the thorax, with special reference to the heart and pleura; and
3) the abdomen, for subdiaphragmatic lesions.

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GENERAL EXAMINATION

3.
General survey of other parts of the body.
Referred pain in the shoulder region. The pain referred from an irritative lesion of the brachial plexus often extends from the base of the neck,
over the top of the shoulder,
and thence into the arm.
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CLASSIFICATION OF DISORDERS OF THE SHOULDER REGIONDISORDERS OF THE SHOULDER (GLENO-HUMERAL) JOINT
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ARTHRITIS

Pyogenic arthritis
Rheumatoid arthritis
Tuberculous arthritis
Osteoarthritis

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MECHANICAL DERANGEMENTS

Recurrent dislocation
Complete tear of the tendinous cuff
Painful arc syndrome
(including calcified deposit in tendon)
Rupture of the long tendon of biceps

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MISCELLANEOUS

Tenosynovitis of the long tendon of biceps.
'Frozen' shoulder


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DISORDERS OF THE ACROMIO-CLAVICULAR j01NT

Osteoarthritis
Persistent dislocation or subluxation

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DISORDERS OF THE STERNO-CLAVICULAR JOINT

Arthritis
Persistent or recurrent dislocation
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Examples for shoulder joint problems

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Shoulder Dislocation/Anterior Instability

Humeral head dislocates from glenoid fossa

Almost always anterior (95%)

Usually traumatic with injury to capsule-labrum complex



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X RAYS

DIAGNOSIS???

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Impingement Signs

• Neer’s Sign
• Arm fully pronated and placed in forced flexion
• Trying to impinge subacromial structures with humeral head
• Pain is positive test
•



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Impingement Signs

• Hawkin’s Sign
• Arm is forward elevated to 90 degrees, then forcibly internally rotated
• Trying to impinge subacromial structures with humeral head
• Pain is positive test




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Rotator Cuff Tear

Partial thickness tear
Full (Complete) thickness tear

May be due to:

Impingement
Degeneration
Overuse
Trauma


Partial tears
Conservative

Complete tears

Surgery


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