Download Apley`s Book, The Shoulder & Pectoral Girdle

The Shoulder
& Pectoral
Girdle (2)
Imaging
•X-ray shows sublaxation,
dislocation, narrow joint space,
bone erosion, calcification in soft
tissues
Arthrography  detecting rotator
cuff tears, Bankart lesions found
with anterior stability
Imaging
•CT scan  cuff tears + labral
detachments
Ultrasound  rotator cuff tears
MRI  rotator cuff pathology –
instability- osteonecrosis of head of
humerus- staging of tumors
Arthroscopy  intra articular
lesions- detachments of the labrumcapsule & impingement or tears of
the rotator cuff
Pathology
Adhesive Capsulitis
•Characterized by progressive pain
and stiffness
It usually resolves after about 18
months
The causes remain unknown
Clinical features
•The patient, age 40-60 years may give a
history of trauma, followed by aching in
the arm and shoulder
Pain gradually increase in severity 
prevent sleeping on the affected side
Stiffness becomes an increasing problem
A frozen shoulder looks quite normal +
some wasting
Not much tenderness marked
There is lack of activity and passive
movements in all directions
Diagnosis
•When patient is seen exclude:
infection, post-traumatic stiffness,
diffuse stiffness and reflex
dystrophy
Calcification of the Rotator
Cuff ( Acute Calcific
Tendinitis)
•Acute shoulder pain may follow
deposition of calcium in the
supraspinatus tendon
The cause is unknown
Clinical features
•The condition affects 30-50 year
olds following overuse
The pain subsides after few days
During acute stage, the arm is held
immobile
Calcification is seen just above the
greater tuberosity on an x-ray
Rupture of Long Head of
Biceps
•Patient always over 50 years
While lifting, the patient feels something
snap in the shoulder & upper arm
becomes painful and bruised
Ask the patient to flex the elbow, you’ll
see a prominent lump in lower part of
the arm
Impingement Syndrome
•Arises from repetitive compressing or
rubbing of the rotator cuff tendons (mainly
supraspinatus) under the coracoacromial
arch
If arm is abducted and then externally and
internally rotated as in cleaning a window,
the rotator cuff may be compressed as it
comes in contact with the acromion process
& coracoacromial ligament
Impingement position ( abduction, slight
flexion, internal rotation)
Instability of the Shoulder
•If the humeral head is not held in place,
recurrent dislocation or recurrent
sublaxation
In 95% of cases the displacement is
anterior
It can also be posterior or
multidirectional
Anterior Instability
•It follows acute injury in which the
arm is forced into abduction, external
rotation, and extension
Posterior Instability
•The condition is due to a violent jerk in
an unusual position
Recurrent posterior instability usually
takes the form of sublaxation when the
arm is used in flexion and internal
rotation
Multidirectional Instability
•The condition is associated with
capsular and ligamintous laxity, and
sometimes with weakness of the
shoulder muscle
Little force is required to displace the
joint
Muscle strengthening and training in
joint control are helpful
Habitual Sublaxation
•Dislocation can occur more or less
spontaneously if there are congenital
anatomical abnormalities or sever
ligamintous laxity
The patient can voluntarily sublaxate or
dislocate the shoulder, painlessly and
reduce it again easily
Tuberculosis
•Constant ache & stiffness lasting many
months
Wasting of muscles around the shoulder
especially the deltoid
Rheumatoid Arthritis
•The most common joint disease to
affect the shoulder
Acromioclavicular erosion discovered on
an x0ray of the chest is the first clue of
the diagnosis
Osteoarthritis
•Patient is usually aged 50-60 years
There is a restriction in shoulder
movement in all directions
Articular space may be narrowed +
osteophyte formation + bone sclerosis
Arthroplasty
•The process of replacing the joint with
an artificial joint
Arthrodesis
•Indications :
Paralysis of the scapulohumeral muscles
Infective disorders of the glenohumeral
joint
Advanced erosive arthritis with massive
disruption of the rotator cuff