www.glenelgorthopaedics.com.au Assessment of the Shoulder Dr. Gavin Nimon Head of Upper Limb Surgery- QEH Senior Lecturer- University of Adelaide MBBS FRACS (Orth) FRCS (Ed)
www.glenelgorthopaedics.com.au Profile Gavin Anthony Nimon University of Adelaide- intern 1990 bst 91-93 Edinburgh/ Newcastle –Orthopaedic Registrar 1994 Advanced Trainee –Orthopaedics 1995-1998 Senior Registrar Year 1999 QEH Senior Registrar/ Consultant PMR Edinburgh Consultant DGRI 2000-2005 Senior Lecturer University of Adelaide- QEH Head of Upper Limb Specialty- The Queen Elizabeth Hospital
www.glenelgorthopaedics.com.au My Approach to Assessing and treating Orthopaedic Issues
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www.glenelgorthopaedics.com.au History
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www.glenelgorthopaedics.com.au Secondary bony Abnormalities Spur Os acromiale
www.glenelgorthopaedics.com.au Assessing The Non-Traumatic Shoulder Pain
www.glenelgorthopaedics.com.au Factors leading to Cuff Tendinopathy
www.glenelgorthopaedics.com.au Cuff Degeneration Normal Cuff Degenerative cuff ( smoker )
Dr. Gavin Nimon www.glenelgorthopaedics.com.au Facts about Rotator Cuff Disease • Degeneration is Normal • Increases with age, relates to genetics, smoking , ? Overhead work • Most tears asymptomatic • Repair Does not guarantee won’t retear • Asymptomatic tears, can be made symptomatic with treatment • Do not know natural history of tear • Evidence that surgery for impingement has no benefit ( but study flawed and surgery often involves Tx of ac joint or cuff) Thus as in OA of hip • Treat symptoms ( unless traumatic tear in young) • Increase treatment as conservative options fail
Dr. Gavin Nimon www.glenelgorthopaedics.com.au Rotator Cuff Treatment • Physiotherapy - Internal/ external Theraband exercises - Hydrotherapy • Cortisone Injections Controversial ( could lead to greater tear) maximum 2-3 • Surgery Arthroscopic vs Open Cuff repair vs debridement In severe cuff disease, ( degenerate) with massive tear ( and atrophy) = Reverse Shoulder Replacement ( ?? Causation in this scenario, and timing)
www.glenelgorthopaedics.com.au Shoulder Arthroscopic Decompression
www.glenelgorthopaedics.com.au Acromioplasty- Decompression Side on view demonstrating Subacromial Spur Spur being excised Spur excised, bone now flat
www.glenelgorthopaedics.com.au Post-op Surgery X-rays AC joint excised arthroscopically Spur excised, not flat undersurface of acromion Opposite AC joint- Not Normal
www.glenelgorthopaedics.com.au Arthroscopic Cuff Repair
www.glenelgorthopaedics.com.au Arthroscopic techniques allow repair of small tears that may have previously been not treated with open techniques
www.glenelgorthopaedics.com.au Factors influencing the recovery after Surgery
www.glenelgorthopaedics.com.au Arthroscopic cuff Repair
www.glenelgorthopaedics.com.au Frozen Shoulder
Dr. Gavin Nimon www.glenelgorthopaedics.com.au Frozen Shoulder- Causation 1. ???? (Idiopathic) 2. Post –Traumatic 3. Diabetic 4. Often first pain may be when reaching behind, but does not mean that is cause
www.glenelgorthopaedics.com.au Diagnosis • Initial Pain (often mistaken for bursitis) • Pain is severe – look miserable • Stiffness (ER =0 degrees) • Age group (20-50) • More common in diabetics, radiotherapy, post breast cancer Treatment:- • Time (longer wait, better outcome in all options) • Hydrotherapy • Corticosteroid injection (+/- hydrodilation) • MUA and injection (risk of fracture) • Arthroscopic release (risk of nerve injury)
www.glenelgorthopaedics.com.au Arthritis and shoulder replacement Anatomic Total Shoulder Replacement Anatomic Reverse Total Shoulder Replacement Cuff Deficiency
www.glenelgorthopaedics.com.au Its very important to be aware of the implant being recommended and that its long term results are within recommended result
www.glenelgorthopaedics.com.au Shoulder Fractures In older patient Shoulder Fixation Reverse Total Shoulder Replacement
www.glenelgorthopaedics.com.au Shoulder Dislocations • Fall on arm ? Abducted and externally rotated • Needs Reduction Kocher/ Hippocratic etc • Sling but then regain ROM • 1 st dislocation (Hovelius study) • Multiple dislocation ( 2 or more – surgery) Hovelius Study- scandinavia (35 years or less) 1 st time dislocator – 85% chance of redislocation Injury Primary Surgical Repair Open Bankart Repair ? Arthroscopic Bankart Repair Prospective RCT Non-op vs scope repair 75% recurrent instability vs 11%
www.glenelgorthopaedics.com.au Shoulder Stabilisation Arthroscopic Labral Repair Non- Anatomic (latarjet)
www.glenelgorthopaedics.com.au Labral SLAP Repairs • Over diagnosed • Often incidental finding • Not usually cause of pain ( but can be in some cases) • Treatment labral repair vs biceps tenotomy/ tenodesis
www.glenelgorthopaedics.com.au Clavicle Fractures • Very Common (Cyclists particularly) • Often Treated Non-operatively • Can accept 1-2 cm shortening and displacement • Surgery- plating • Risks of N/V injury
Dr. Gavin Nimon Dr. Gavin Nimon www.glen-orth.com www.glen-orth.com AC Joint injuries Type to enter text Grade 1-6 – Really “sprain” or “out” – Grade >4 (?3) do better with surgery – Surgery best < 2 weeks – 3-6 months off sport 27/11/09
Dr. Gavin Nimon Dr. Gavin Nimon www.glen-orth.com www.glen-orth.com Type to enter text Grades of ac joint Injury 27/11/09
Dr. Gavin Nimon Dr. Gavin Nimon www.glen-orth.com www.glen-orth.com Type to enter text 27/11/09
Dr. Gavin Nimon Dr. Gavin Nimon www.glen-orth.com www.glen-orth.com A-C Joint injury Type to enter text Fall on tip of shoulder or force transmitted through arm (straight) 27/11/09
Dr. Gavin Nimon Dr. Gavin Nimon www.glen-orth.com www.glen-orth.com www.glen-orth.com Type to enter text POST AC JOINT RECONSTRUCTION 27/11/09
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