Shoulder and Elbow Problems

Mr Amir Salama

Consultant Orthopaedic Surgeon

Heart of England Trust

Parkway Hospital

Shoulder Pain

Subacromial space: Impingment or bursitisRotator cuff tear

Gleno-humeral jointFrozen Shoulder( Adhesive capsulitis)Arthritis

Acromio clavicular Joint: Arthritis , Dislocation, Arthrolysis.

Biceps tendon Tendonitis,SLAP lesion, subluxation

Instability: Usually Ant, but could be Post., or Multidirectional

Neoplastic

Traumatic/ Injury

fracture

Dislocation/ instability

SLAP

Cuff tear

Non Traumatic

Impingment

Diagnosis

Pain on forward elevationPain on internal rotationCan’t sleep on the shoulder

Test : Impingment test

Management

Analgesics

Physio

Injection

Surgery

Arthroscopic Subacromial decompression (SAD)Day case

Completely advance the needle in a perpendiculardirection under the acromion, aimingin a slightly cephalad direction.

Subacromial Injection Posterior : easierLateral: ? better

PosteriorLateral

Rotator Cuff Tear

Diagnosis

4 muscles (SITs)

SupraspinatusInfraspinatusTeres minorSubscapularis

Supra Infra

Management

Imaging

xray: early ---- Normallater ----upword migration of the humerus

USS vs MRI

AnalgesicsPhysioInjectionsSurgery

ArthroscopicDay caserecovery: 6-8 wks

Reverse Shoulder replacement

Calcific Tendonitis

Diagnosis

Management

Simillar to impingment

Pain can be acute and severe

AnalgesicsPhysioInjectionSurgery---Arthroscopic removal of calcification + SAD

---day case, quick return to work

Frozen Shoulder

Diagnosis

Management

-Pain –early-Stiffness –later

Normal xray

Test: Ext.Rotation

AnalgesicsPhysioInjectionSurgery---MUA: Old fashion, fracture, recurrence

Arthroscopic capsular release---day case, quick return to work

Anterior approachPosterior approach

Glenohumeral joint: frozen shoulder

Coracoid

ACJ pain:

Diagnosis

ManagementAnalgesicsPhysioInjectionSurgery- Arthroscopic excision of ACjoint

---day case, quick return to work

Cross body adduction(scarf test)Pain

arthritis, osteolysis

“walk” the needle along the lateral clavicle

AC Joint Injection:

- tenderness to palpation of the AC joint, - pain with active or passive adduction (Scarf test) (reaching the arm across the body)

slanting Joint

ACJ Separation/dislocation

Diagnosis

Arthroscopic Tightrope stabilisation

Day caseArthroscopic scarHigh patient satisfaction

Gleno-humeral arthritis

Diagnosis

-Shoulder pain- Movement/stiffness

-X-ray

-Degenerative-Post injury

AnalgesicsPhysioInjectionSurgery---Arthroscopic capsular release and debridment

---day case, quick return to work

Arthroplasty

Management

Reverse Shoulder replacement

Tensioning the deltoid and increasing the deltoid moment arm by medializing the center of rotation are biomechanically advantageous.

Indications:PseudoparalysisIncompetent coraco acromial arch(anerior escapr)Low functional demand patientPysiological age >70Sufficient Glenoid bone stockWorking Deltoid muscle, Intact axillary nerve

•Contraindications •deltoid deficiency•bony acromion deficiency •glenoid osteoporosis/bone deficiency•active infection

Dislocation

Young person-recurrent dislocation(instability)

?? Bone defect

Old person-Rotator cuff tear

Apprehension test

Management

-Physiotherapy

-Surgery: Arthroscopic Stabilisation (day case)- If Bone defect----Bone Graft (Laterjet procedure)

Diagnosis

?MRI scan

Instability

Biceps tendon: Weight lifters, masons, and rock climbers

-pain with palpation of the tendon-positive Speed's test

Injection: Do not inject the tendon itself

Anterior Shoulder pain

Surgery:---Biceps tenotomy or tenodesisArthroscopicDay case

Diagnosis

Management

Proximal biceps rupture

- Usually no functional disability ( supination 21% , Flexion 8%)

- In young athlete--think of tenodesis.

Shoulder Pain

Subacromial space: Impingment or bursitisRotator cuff tear

Gleno-humeral jointFrozen Shoulder( Adhesive capsulitis)Arthritis

Acromio clavicular Joint: Arthritis , Dislocation, Arthrolysis.

Biceps tendon Tendonitis,SLAP lesion, subluxation

Instability: Usually Ant, but could be Post., or Multidirectional

Traumatic/ Injury

fracture

Dislocation/ instability

SLAP

Cuff tear

Non Traumatic

Thank YouMr Amir Salama

Consultant Orthopaedic SurgeonHeart of England Trust

Parkway Hospital

AnalgesicsPhysioInjectionSurgery---Arthroscopic capsular release

---day case, quick return to work

Cuff Tear

Diagnosis

Management

Hamada Classification of Arthritis in chronic rotator cuff tears (Hamada K, CORR 1990;254:92). Stage 1: Acromiohumeral interval greater than 6 mm. Stage 2: Acromiohumeral interval less than 7 mm. Stage 3: Acromiohumeral interval less than 7 mm with acetabulization of acromion. Stage 4a: Acromiohumeral interval less than 7 mm with glenohumeral arthritis without acetabulization. Stage 4b: Acromiohumeral interval less than 7 mm with acetabulization and glenohumeral arthritis. Stage 5: Acromiohumeral interval less than 7 mm with osteonecrosis of humeral head.