12/10/2016 Disclosures � None SNAP, CRACKLE, POP ACUTE SHOULDER TRAUMA Nicholas Colyvas MD Orthopedic Surgery and Sports Medicine UCSF Shoulder 4 12/10/2016 1
12/10/2016 OBJECTIVES � Define the most common acute shoulder trauma issues � Discuss the nature of these injuries: history, physical exam and imaging � Go through the treatment options 5 12/10/2016 OBJECTIVES Acute Shoulder Injuries � Rotator cuff tears � Not comprehensive � Biceps tendon rupture � Will focus on understanding the pathology and � AC joint rationale of treatment � Shoulder dislocations / Instability � Will try to highlight what to look for as a PCSM physician � Fractures • Clavicle � When to refer to Ortho • Proximal humerus 8 12/10/2016 2
12/10/2016 Acute Shoulder Injuries Rotator Cuff Anatomy � Rotator cuff tears � Biceps tendon rupture � AC joint � Shoulder dislocations / Instability � Fractures • Clavicle • Proximal humerus 9 12/10/2016 Shoulder: Rotator Cuff � The rotator cuff is the group of tendons that stabilize the shoulder joint ROTATOR CUFF DISEASE � Damage to rotator cuff can be from acute injury or repetitive strains • Degeneration with aging or inflammation from tendinitis, bursitis, or arthritis • Trauma (sports, falling, repetitive overhead motions) 3
12/10/2016 Presentation Rotator cuff tears � Partial RC tears � Older age group, predominantly male • First treated conservatively, RC repair if conservative management fails � Full-thickness RC tears � May have had some more chronic shoulder symptoms • Severe weakness and limited ROM • Zipper phenomenon: Generally start in supraspinatus and progress posteriorly to � Distinct episode, often associated with a feeling of a pop or tearing infraspinatus sensation • Long head of biceps can rupture secondary to upward displacement of humeral head since supraspinatus tendon lo longer present � Acute loss of function, some swelling and pain as a spacer • Tear can progress across bicipital groove to involve subscapularis � A subgroup that does better with surgical treatment- consider early • surgery imaging 13 12/10/2016 Surgery: Rotator cuff repair Rotator cuff repair results/outcomes � Chronic tears: Surgery recommended if symptoms of 6-12 months, large tear ≥ 3cm, significant weakness or loss of function, or recent acute injury � Acute tears do better � Acute tears: Operate as soon as possible, therefore have a � Smaller tears do better high degree of suspicion based on history and exam � Risk of re-tear � Consider injection/MRI early to facilitate decision making � Re-tear does not always necessitate more surgery � May not recover full function 16 12/10/2016 4
12/10/2016 Acute Shoulder Injuries BICEPS TENDON � Rotator cuff tears � Biceps tendon rupture RUPTURE OF THE LONG HEAD OF the BICEPS � AC joint � Shoulder dislocations / Instability � Fractures • Clavicle • Proximal humerus 17 12/10/2016 BICEPS TENDON RUPTURE (long head) BICEPS TENDON Presentation two proximal attachments 5
12/10/2016 BICEPS TENDON RUPTURE (long head) Biceps Rupture Popeye deformity � Diagnosis made clinically � Obtain an MRI to look at associated Rotator cuff pathology if clinically indicated � Not usually surgical, do well with rehab � Will lose some supination strength, minimal flexion strength- approx 15% � Consider surgery in younger/dominant arm/higher level sports or work Strength loss Acute Shoulder Injuries � Rotator cuff tears � elbow flexion was diminished by 16%, of supination of the forearm by 11%, � Biceps tendon rupture and of shoulder abduction by 16%. � AC joint � The patients who underwent surgery lost, on average, only 8% strength for elbow flexion and 7% for forearm supination. Shoulder abduction was decreased by 20%. � Shoulder dislocations / Instability � Fractures • Clavicle � Arch Orthop Trauma Surg. 1986;105(1):18-23. Muscular strength after • Proximal humerus rupture of the long head of the biceps. � Sturzenegger M, Béguin D, Grünig B, Jakob RP. � 23 12/10/2016 24 12/10/2016 6
12/10/2016 AC Joint injuries Type 1: no surgery � Approx 12% of dislocations � Males: female ratio 5:1 � Common in contact sports � Direct blow 25 26 Rockwood 12/10/2016 12/10/2016 Type 2: no surgery Type 3: somewhat controversial. 27 12/10/2016 28 12/10/2016 7
12/10/2016 Type 5: Surgery Types 4 and 6-rare, surgery 29 30 12/10/2016 12/10/2016 AC Joint injuries Acute Shoulder Injuries � Rotator cuff tears � Most treated conservatively and will do well � Biceps tendon rupture � Cosmetic deformity � AC joint � Surgery for grade 3 or more � Shoulder dislocations / Instability � Surgery is not without its problems � Fractures • Clavicle • Proximal humerus 31 12/10/2016 32 12/10/2016 8
12/10/2016 Anterior dislocations Shoulder dislocations � Bimodal age distribution � Most common joint to dislocate due to • Largest group are young adult men mobility who sustain high-energy injuries � Subluxation: partial dislocation � Mechanism • Violent external rotation in abduction � Complete dislocation: Separation of causes humeral head to leave glenoid humerus from scapula at glenohumeral socket, damaging soft tissue joint structures (Bankart lesion) � Anterior dislocations, Posterior dislocations, or Inferior dislocations • As posterior part of humeral head exits joint, it can collide with anterior rim of glenoid, creating a bony � Over 95% of glenohumeral dislocations indentation (Hill Sachs lesion) are anterior Presentation Considerations Presentation considerations � Bone Injury � Nerve Injury • X-ray before reduction r/o humeral fracture • About 10% sustain injury to axillary nerve • Must get an Axillary view: determines direction of dislocation • Brachial plexus injury more unusual • Always check NV status � Vascular injury � Rotator Cuff tears • Very rare, older patients have less elasticity in axillary artery • Between 14-65% associated with rotator cuff tears • Always check NV status before and • Increasing incidence in older patients: after relocation • have a degree of suspicion in older patients 9
12/10/2016 Treatment Treatment � Post-reduction treatment � Reduction • Sling with the arm in external rotation for • No consensus on optimum 1-3 weeks technique • Physical therapy • May take up to 3 months to regain function • Ideally reduced with the patient relaxed: under regional or even � Recurrent dislocations risk variable with age general anesthesia, but in • For patients <20, risk up to 95% practice initial reduction usually • For patients 20-25, risk 50-75% attempted • Older patients, remember high risk of rotator cuff tear After relocation Surgery � Generally for recurrent dislocators � XR � Anatomic repairs focus on repairing disrupted structure � Ice /NSAIDS • Labral repair ‒ Bankart repair � period of immobilisation ‒ Posterior labral repair ‒ SLAP repair � PT ‒ Latarjet for recurrent dislocations with bone loss 39 12/10/2016 10
12/10/2016 Acute Shoulder Injuries Clavicle fractures � Account for approximately 5% of all fractures � Rotator cuff tears • Most common type of pediatric fracture � Biceps tendon rupture • Twice as common in males � AC joint � Usually a result of acute trauma � Shoulder dislocations / Instability � Fractures � Most often fractured in the middle third of its length • Clavicle • Proximal humerus � XR 41 12/10/2016 43 12/10/2016 44 12/10/2016 11
12/10/2016 Clavicle fractures CLAVICLE FRACTURES ORIF Danger ! • Nondisplaced or minimally displaced fractures treated conservatively • If necessary, displaced fractures treated with ORIF • Surgery Criteria ‒ Complete displacement, bayonetting ‒ Skin tenting ‒ Significant comminution ‒ 2cm shortening ‒ NV compromise Distal clavicle fracture 47 12/10/2016 48 12/10/2016 12
12/10/2016 Acute Shoulder Injuries Proximal Humerus Fractures � Account for about 5% of all fractures � Rotator cuff tears � Common in older patients who from a ground-level fall � Biceps tendon rupture � Higher level of trauma required for young person to sustain injury � AC joint � Complications � Shoulder dislocations / Instability • Neurological injury incidence is high ‒ 59% for nondisplaced, 82% for displaced � Fractures ‒ Axillary nerve most common • Clavicle • Proximal humerus • Stiffness 49 12/10/2016 Surgical indications Operative treatment options � Displacement of fragment by ≥ 1cm or angulation between fragments ≥ 45 degrees � Locking Plating � Percutaneous Pinning � Greater tuberosity should be reduced if � Screw Tension Band Technique displacement ≥ 5 mm • Screw inserted from shaft up into head • Figure of 8 tension band wiring passed � Other factors (bone quality, fracture around cuff origin on greater tuberosity orientation, soft tissue injuries, age and health • Hole made in humeral shaft of patient) important • Second wire inserted through both tuberosities � 2 and 3 part fractures treated with ORIF � Shoulder replacement � IM nailing � 4 part fractures treated with ORIF in younger patients, hemiarthroplasty in older patients with osteoporosis 13
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