Shoulder_joint_and_applied_aspects[1].pptx

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1. SHOULDER JOINT AND ITS APPLIED ASPECTS Presenter- DR.Nipendra Kishore

2. Introduction SHOULDER GIRDLE Sternoclavicular joint Acromioclavicular joint Glenohumeral joint(shoulder joint) Scapulothoracic joint

3. Osteology Clavicle Scapula Humeral head

4. Humeral head version - (0-55 degree of retroversion) Glenoid version - 1.5 degrees of retroversion Normal position of glenoid surface in relation to scapular body ranged from 2 degree of anteversion to 7 degree retroversion

5. Articulations Sternoclavicular joint Only true joint Anterior and posterior Sternoclavicular ligaments Costoclavicular ligament Posterior is strongest primary retsrains to anteroposterior stability Acromioclavicular joint Diaryhroidal joint containing incomplete articular disc Facets are covered with fibrocartilage Acromioclavicular ligament(anterior,posterior,superior and inferior ligaments) Superior fibres blend with capsule of trapezius and deltoid When arm is maximally elevated about 5 to 8 degree rotation possible Corococlavicular ligament(conoid and trapezoid ligaments)

6. Scapulothoracic joint Medial border of scapula articulates with posterier aspect of second to seventh rib Angled 30 degree anteriorly and 3 degree upward tilt

7. Shoulder joint It is a synovial joint of ball and socket varietty Glenohumeral articulation Weak joint(Glenoid cavity is too small and shallow) Greatest range of motion in body Stability due to STATIC and DYNAMIC stabilisers

8. Static stabilisers Articular anatomy Glenoid labrum Glenohumeral ligaments Capsule and negative intra articular pressure Dynamic stabilisers Rotator cuff and biceps tendon Scapulothoracic mechanics

9. Capsule Loose and permits free range of movements Least supported inferiorly Medially attached to scapula beyond supra glenoid tubercle and margins of labrum Laterally to anatomical neck of humerus with exceptions ( inferiorly extends down to surgical neck ) Superiorly deficient for passage of long head of biceps Capsuloligamentus structures is the primary static stabiliser of shoulder

10. LIGAMENTS Glenohumeral ligaments Discrete capsular thickenings 3 weak Bands (superior,middle,inferior)of fibrous tissue that strengten the anterior capsule Transverse humeral ligaments Bridges upper part of bicipital groove of humerus Tendon of long head of biceps pass deep to it

11. Coracohumeral ligament From root of corocoid process to neck of humerus It strengten the capsule Coracoacromial ligament Extends between corocoid process of scapula and acromion Ligament is a constraint to superior escape of humeral head Key component of corocoacromial arch

12. Musculotendinous cuff of shoulder Fibrous sheath Formed by 4 flattened tendons(subscapularis ,supraspinatus,infraspinatus and teres minor) blend with capsule of joint Acromion, coracoacromial ligament and coracoid process form coraco acromial arch (secondary socket for head of humerus)

13. ROTATOR INTERVAL:- Triangular space between anterior border of supraspinatus and superior border of subscapularis Base of triangle is formed by coracoid Contents :- SGHL,CHL and Biceps tendon Tightening this interval can decrease the inferior translation BICEPS PULLEY : SGHL, CHL, Subscapularis form an anterior pulley to keep biceps tendon located in joint / bicepetal groove

14. ROTATOR CABLE :- Curved structure , which is an extension of corocohumeral ligament in anterior direction It blends with anterior subscapularis and supraspinatus tendon Cable runs from anterior to posterior under the supraspinatus tendon and infraspinatus tendon to blend with posterior infraspinatus and teres minor tendons Connects supraspinatus and infraspinatus to head of humerus and function to transmit forces across rotator cuff complex

15. Muscles around Shoulder Intrinsic group Rotator cuff muscles Deltoid Pectoralis major Teres major Latismus dorai Biceps brachii

16. Extrinsic group Rhomboids Levator scapulae Trapizius Serratus anterior

17. Muscles connecting upper limb to vertebral column : Trapizius ,latissimus dorsai, both rhomboids muscles and levator scapulae Muscles connecting upper limb to thoracic wall : both pectoralis muscle ,subclavius , and serratus anterior Suprascapularnotch:- suprascapular ligament converts notch into foramen Suprascapular nerve passes below the ligament ,and artery and vein above ligament Splinoglenoidnotch:- splenoglenoid ligament that bridges the notch

18. Movements of shoulder Girdle Elevation - by upper fibres of Trapizius and levator scapulae Depression -by lower fibres of serratus anterior and pectoralis minor Protraction - serratus anterior and pectoralis major Retraction - by Rhomboids and middle fibres of Trapizius Lateral or forward rotation - by upper fibres of Trapizius and lower fibres of serratus anterior Medial or backward rotation -by Levator scapulae and Rhomboids Movements of schoulder girdle are always associated with movements of scapula .movement of scapula may or maynot associated with movements of shoulder

19. Spaces around scapula Quadrangular space Triangular space Triangular interval

20. Blood supply Posterior circumflex Humeral vessels Anterior circumflex Humeral vessels Suprascapular vessels Subscapular artery Nerve supply Axillary nerve Musculocutaneous nerve Suprascapular nerve

21. Bursae related to joint Subacromial bursa(subdeltoid bursa) Subscapular bursa Infraspinatus bursa

22. Examination of shoulder joint History:- Age and chief complaints Instability , acromioclavicular joint injuries ,and distal clavicle osteolysis are common in young patinets Rotator cuff tears , arthritis ,and proximal humerus fractures are common in older people Direct blow are usually responsible for acromioclavicular separations Instability occurs with injury to abducted extrernally rotated arm Chronic overhead pain and night pain are associated with rotator cuff tears

23. CODMAN’S METHOD Method of palpation of shoulder joint Exeminers left hand used for right shoulder Thumb lies below the spine of scapula to palpate posterior aspect of shoulder Tip of index finger is used placed anterior to acromium to feel superior aspects and anterior aspects of shoulder and other 3 fingers are placed on clavicle to hold it Examiners right hand grasps the patients flexed elbow and patient arm is moved gently backwards and forwards and shoulder joint is carefully palpated

24. Examination of shoulder joint Neer impingement sign and impingement test:- Affected arm ( Forward elevation )+stabilising scapula Causing the greater tuberosity to impinge against the acromium Impingement test with use of subacromial injection of 10 ml of 1 % lidocaine . Pain caused by impringement is significantly reduced

25. HAWKINS -KENNEDY TEST:- Forward flexing humerus to 90 degrees+ forcible internal rotation of the shoulder JOBE TEST :- Shoulder in 90 degree of abduction and 30 degrees of forward flexion and internal rotation . Supraspinatus testing against resistance shows weakness or insufficiency owning to tear or pain associated with rotator cuff impingement INTERNAL ROTATION RESISTANCE STRESS TEST:- Zaslav described this test.To differentiate between internal and classic oulet impingement.Patients arm in 90 degrees of abduction the coronal plane and 80 degrees of external rotation.A manual isometric mucle test is performed for external rotation and compared with one for internal rotation in same position

26. PAINFUL ARC TEST :- Arm in full elevation and slowly bring down arm to side.In between 90 degrees and 120 degrees the patient feels pain test is considered positive GERBER SUBCORACOID IMPINGEMENT TEST To identify impingement between rotator cuff and coracoid process.Arm is forward flexed 90 degrees and abducted 10 to 20 degrees across the body to bring the lesser tuberosity into contact with coracoid Pain indicates coracoid impingement

27. JOBE APPREHENSION -RELOCATION TEST:- To distinguish between primary and secondary impingement.Patient supine ,arm abducted 90 degrees and externally rotated produces pain. Application of posteriorly directed force to humeral head ,relocating it in glenoid does not change the pain in patients with secondary impingement SPEED TEST:- Flex shoulder 90 degrees with elbow extended and forearm supinated.Resistance applied to forearm, positive result produce pain in bicipital groove

28. YERGASON SIGN:- Elbow flexed to 90 degrees ,the forearm pronated .The patient attempt to supinate forearm activly against resistance LIFT OFF TEST:- For detection of isolated rupture of subscapularis tendon.With patient seated/standing arm is internally rotated dorsum of hand is placed against Lower back.If test is positive unable to lift the hand.

29. BELLY PRESS TEST:- Patient presses abdomen with flat of the hand and attempts to keep the arm in maximal internal rotation If strength of subscapularis is impaired , maximal internal rotation cannot be maintained EXTERNAL ROTATION STRESS TEST:- To test integrity of Infraspinatus and Teres minor.With the arm side in neutral flexion and abduction , shoulders are externally rotated 45 to 60 degrees.Examiner applies force against dorsum of hand,attempting to rotate shoulder internally back to neutral while patient is asked to resist

30. EXTERNAL ROTATION LAG SIGN:- To test the integrity of supraspinatus and infraspinatus tendons.elbow passivly flexed to 90 degrees ,and the shoulder is held at 20 degrees of elevation and near maximal external rotation by the examiner The patient asked to maintain external rotation .The sign is positive when a lag or angular drop occurs PATTE SIGN:- To determine the strength of the teres minor.Patient standing examiner elevates patients arm to 90 degrees in scapular plane and flexes elbow to 90 degrees .Patient asked to laterally rotate shoulder

31. DROP SIGN:- To test the integrity of Infraspinatus .The affected arm held in 90 degrees of elevation in scapular palne and at almost full external rotation with elbow flexed at 90 degrees.The patient asked to mainatin position activly as examiner releases the wrist while supporting the elbow ,which is mainly function of Infraspinatus INTERNAL ROTATION LAG SIGN:- To test the integrity of subscapularis tendon Affected arm is held in maximal internal rotation Elbow flexed to 90 degrees ,shoulder held at 20 degrees of elevation and 20 degrees of extension.Dorsum of hand is partially lifted away from lumbar region until almost full internal rotation is reached

32. APPLIED ASPECTS OF SHOULDER JOINT ADHESIVE CAPSULITIS ( FROZEN SHOULDER ) It describes contracted ,thickened joint capsule that seemed to be drawn tightly around humeral head with relative absence of synovial fluid and chronic inflammatory changes within the subsynovial layer Pathologic changes in adhesive capsulitis are synovial inflammation with sussequent reactive capsular fibrosis RISKFACTORS - female gender , age above 50 yrs ,DM, Prolonged immobilisation, Hyperthyroidism, Stroke or Myocardial infarction,Presence of autoimmune diseases and trauma Frozen shoulder -PRIMARY OR SECONDARY(based on inciting event present or not)

33. There is no universal accepted criteria to diagnose Frozen shoulder Internal rotation is lost initially,followed by loss of flexionand external rotation Clinical caurse of primary frozen shoulder consists of 3 phases Secondary may not exhibit all 3 phases PHASE 1 - PAIN (gradual onset of diffuse shoulder pain) progresses over weeks to months .Pain usually worse at night and exacerbated by lying on affected side PHASE 2 - STIFFNES, usually lasts for 4 to 12 months .Patient describes difficulty with activity PHASE 3 - THAWING , Usually lasts for weeks or months ,as motion increases , pain diminishes

34. Treatment :- Self limiting condition lasting 12 to 18 months Treatment options include benign neglect,supervised physical therapy ,NSAIDS,oral corticosteroids,intraarticular steroid injections,distention arthrography,closed manipulation,open surgical release and arthroscopic capsular release

35. CALCIFIC TENDINITIS:- Painful,self limited disorder of rotator cuff in which tendons are infiltrated with calcium deposits Most common site of occurance supraspinatus tendon( 1.5 to 2 cm away from tendon insertion on greater tuberosity) Women between ages of 30 and 60 years are most freequently affected (women are affected more than men) Most patients are asymptomatic ,but pain is intense in symptomatic patients ( subacromial pain) Hypoperfusion…calcification(vascular etiology with degeration of tendon fibres preceding calcification)

36. CALCIFIC TENDINITIS follows a definite progression PHASE 1 :- PRECALCIFICATION STAGE .Site undergoes fibrocartilaginous metaplasia (Asymptomatic stage ) PHASE 2 :- CALCIFICATION STAGE . Calcium deposit into matrix vessels ,excreted by cells and coalesce to larger calcium deposits. Phase of Formation……Resting phase …...Resorptive phase PHASE 3 :- POST CALCIFICATION STAGE

37. TREATMENT:- Non operative - physical therapy,exercises ,Anti Inflammatory medications and corticosteroid injections Surgical treatment - Indications - symptom progression, constant pain that interferes with activities of daily living and absence of improvement after conser vative methods

38. IMPINGEMENT SYNDROME:- In 1972 ,Neer described impingement syndrome characterised by a ridge of proliferative spurs and excrescences on the undersurface of anterior process of acromium apparently caused by repeated impingement of rotator cuff and humeral head with coracoacromial ligament Supraspinus insertion into greater tuberosity that passes beneath the coracoacromial arch during forward flexion of shoulder are succeptible to impingement syndrome Four types of impingement :- PRIMARY ,SECONDARY,SUBCORACOID AND INTERNAL IMPINGEMENT

39. ROTATOR CUFF TEAR Loss of continuity of rotator cuff can be described in ACUTE OR CHRONIC PARTIAL OR FULL THICKNESS TRAUMATIC OR DEGENERATIVE

40. Majority of tear involves supraspinatus and infraspinatus Tears associated with chronic impingement syndrome typically begin on the bursal surface or within tendon substance Tears occur in articular surface because of tension failure in younger patients participating in overhead activities Patient typically presents with an insidious onset of pain exacerbated by overhead activities Complaints of night discomfort,pain in deltoid region,muscle weakness and difference in active and passive range of motion are common Acute pain and weakness may be seen after traumatic rotator cuff rupture

41. TREATMENT Non operative :- asymptomatic full thickness tear, non complaint patients ,medical contraindications to surgery Activity modification ,stretching and strengthening exercises antiinflammatory medications Operative :- significant pain, chronic full thickness tear that failed to respond to non operative methods

42. GLENOHUMERAL INSATABILITY:- Symptomatic and pathologic condition in which humeral head does not remain centered in the glenoid fossa OTA Classification :-in the system shoulder region is 10 A letter used to identify specific joint (A- Glenohumeral , B - Sternoclavicular etc) Followed by another number (1- Anterior,2- posterior,3-lateral 4- medial,5 - inferior)

43. ANTERIOR INSTABILITY:- Most common type of shoulder instability Typically the result of trauma to arm when in abducted and external rotated position Highly painful POSTERIOR INSTABILITY:- The result of trauma when arm in adduction and internal rotation Minimally painful Epilepsy and electric shock are freequent causes INFERIOR INSTABILITY:- LUXATIO ERECTA Hyperabduction injuries

44. Surgical approaches to shoulder joint Anterior approach :- Anterior incision - Make 10- 15 cm straight incision following lines of deltopectoral groove ( incision should begin above coracoid process) Axillary incision - make vertical incision 8 to 10 cm long starting from midpoint of anterior axillary fold and extending posteriorly to axilla -After skin incision and subcutaneous dissection ,the interval between Anterior deltoid and pectoralis major muscle is identified (deltopectoral interval) -Cephalic vein is taken laterally

45. -underlying clavipectoral fascia can be incised at the lateral edge of coracobrachialis -conjiont tendon is pulled medially giving exposure of Subscapularis muscle and tendon -subscapularis muscle and tendon may split iwith it's fibres 1 cm medial to insertion of insertion and reflected medially -capsule can be incised a number of ways preferably T incision Posterior approach :- Incision:- linear incision along the entire length of scapular spine,extending to the posterior corner of acromion .Alternatively make a 10 to 15 cm longitudnal incision centered on a point 2 cm inferomedial to the posterior corner of acromium

46. -intravenous plane between teres minor and infraspinatus muscle - identify origin of deltoid on scapular spine and detach it -identify intravenous plane between infraspinatus and teres minor muscle -retract infraspinatus superiorly and teres minor inferiorly to reach posterior region of glenoid cavity and neck of scapula -Posterioinferior corner of shoulder joint capsule is exposed -Incise it longitudnally ,close to scapula