Dr. JS Kirsten Louis Leipoldt Medical Centre Room 333, Broadway
Transcript of Dr. JS Kirsten Louis Leipoldt Medical Centre Room 333, Broadway
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GLENOHUMERAL GLENOHUMERAL
INSTABILITYINSTABILITY
Dr. JS KirstenDr. JS Kirsten
Louis Leipoldt Medical CentreLouis Leipoldt Medical Centre
Room 333, Broadway, BellvilleRoom 333, Broadway, Bellville
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Historical overviewHistorical overview
• Early descriptions
– Hippocrates 460 BC
• Anterior capsule
– Thirteenth century
• Humeral head defect
– 1861
• Rotator cuff injuries
– 1880
• Muscle defects
– 1954
– Subscapularis tendon
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Historical overviewHistorical overview
• Treatment of acute
traumatic dislocation
– Hippocrates: Six
different techniques
– Kocher - 1817
– Milch - 1938
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Historical overviewHistorical overview
• Posterior
glenohumeral
instability - 1839
– Diagnosis without x-
rays
– X-rays discovered late
1800’s
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Historical overviewHistorical overview
• Operative
reconstruction for
anterior instability
– Hippocrates: White hot
poker to scar capsule.
– More refined
techniques - 1868 -
1923 (Bankhart)
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Relevant AnatomyRelevant Anatomy
• Skin
– Cosmetically
acceptable incisions in
lines of skin.
• First muscle layer
– Deltoid
– Supplied by axillary
nerve
– Surgical approaches
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Relevant AnatomyRelevant Anatomy
• Coracoacromial arch
– Coracoid serves as
landmark during
surgery.
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Relevant AnatomyRelevant Anatomy
• Humeral scapular
motion interface.
– Not moving: Deltoid,
coracoid muscles,
acromion,
coracoacromial
ligament.
– Moving: Rotator cuff,
long head of biceps,
humeral tuberosities.
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Relevant AnatomyRelevant Anatomy
• Rotator cuff
– Subscapularis
– Rotator interval
– Supraspinatus
– Infraspinatus
– Long head of biceps
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Relevant AnatomyRelevant Anatomy
• Scapulohumeral
ligaments
– Superior glenohumeral
ligament, middle
glenohumeral
ligament, inferior
glenohumeral
ligament.
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Relevant AnatomyRelevant Anatomy
• Scapulohumeral ligaments
– Relaxed throughout most of range of motion.
– Play role primary in positions near extremes
of motion.
– Proprioceptive function.
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Relevant AnatomyRelevant Anatomy
• Glenoid labrum
– Consists of tense
fibrous tissue.
– Anteriorly continuous
with inferior
glenohumeral
ligament.
– Plays role in stability
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Relevant AnatomyRelevant Anatomy
• The scapular humeral ligaments under tension– Superior glenohumeral ligament:
• External rotation in adduction.
– Middle glenohumeral ligament:• External rotation in abduction to 45 degrees.
– Inferior glenohumeral ligament:• Anterior band in wide abduction and external rotation.
• A posterior band together with rotator interval when humerus elevated anteriorly in sagittal plain (flexion).
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Net humeral joint
reaction force
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Effective glenoid
arch.
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Glenoid versionGlenoid version
• Angle that glenoid centre line makes with
plain of scapula.
• Altered by dysplasia, fractures, osteotomy,
arthroplasty.
• Abnormal relationship to forces generated
by scapulohumeral muscles.
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Glenoid version
• Scapular
positioning
• Ligaments
• Rotator cuff.
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Glenoid version
• Scapular
positioning
• Ligaments
• Rotator cuff.
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Glenoid version
• Scapular
positioning
• Ligaments
• Rotator cuff.
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Glenoid version
• Scapular
positioning
• Ligaments
• Rotator cuff.
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Mechanism of glenohumeral Mechanism of glenohumeral
stabilitystability
• Net humeral joint
reaction force
directed within
effective glenoid arch.
• Glenoid and humeral
joint surfaces
congruent.
• Head will remain
centered.
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Net humeral joint reaction forceNet humeral joint reaction force
• Rotator cuff
• Deltoid
• Long head of
biceps.
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Net humeral joint reaction forceNet humeral joint reaction force
• Strengthening and neuromuscular training
optimize control.
• Control impaired by injury, disuse,
contracture, paralysis, loss of coordination,
tendon deffects.
• Control guided by proprioceptors in labrum
and ligaments.
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Net humeral joint reaction forceNet humeral joint reaction force
• Generalized joint laxity - less acute
propriocepsion and altered muscle activation.
• Propriocepsion compromised by traumatic
anterior instability.
• Propriocepsion is restored one year after
surgical reconstruction.
• Neuromuscular stabilization, capsular feedback
and pattern generators, muscle optimization.
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Scapular positioningScapular positioning
• Scapular alignments increase range of positions in which joint is stable
• Coordination of scapular positioning and glenohumeral muscle balance improved by neuromuscular control
• Most throwing and striking skills shoulder abduction angle usually 100 degrees.
• Higher and lower release points achieved by tilting trunk
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LigamentsLigaments
• Strength: Amount of tension before
failure.
• Laxity: Amount of translation or rotation it
allows.
• Laxity does not determine stability.
– Asymptomatic gymnasts or school children.
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Ligamentous stabilizationLigamentous stabilization
• Serves as check
reigns.
– Restrict joint position.
– Muscle balance act as
stabilizing force by
compressing head.
– Altered by scapular
position.
– Altered by surgical
capsular tightening.
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Ligamentous stabilizationLigamentous stabilization
• Act as countervailing
force.
– Compresses humeral
head into glenoid
fossa.
– Resists displacement.
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Ligamentous stabilizationLigamentous stabilization
• Obligate translation.
– When joint is forced to
extremes of motion.
• Late cocking and early
acceleration phase in
throwing.
– Posterior labral tears
and calcification.
– Surgically over
tightening ligaments.
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Adhesion/CohesionAdhesion/Cohesion
• Molecular action of fluid to itself and to
joint surfaces.
• Joint fluid: High tensile strength, low
shear strength.
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Adhesion/CohesionAdhesion/Cohesion
• Inflammatory disease lowers cohesion.
• Degenerative joint disease lowers wet
ability of surfaces
• Displaced articular fracture or small
glenoid diminishes contact area.
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Glenohumeral suction cupGlenohumeral suction cup
• Seal of labrum and capsule to humeral head.
• Flexible peripherally.
• Rigid centrally.
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Glenohumeral suction cupGlenohumeral suction cup
• Centers humeral head in glenoid in midrange positions without muscle action.
• Capsule and ligaments not under tension
• Defect in labrum or capsule eliminate suction cup effect
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Limited joint volumeLimited joint volume
• Scarcity of fluid in joint.
• Osmotic action of sinovium.
• Lower osmotic pressure in sinovial interstitium.
• Constant negative pressure in joint.
• Attempted distraction lowers inter articular
pressure more.
• Reduced if joint is vented or compliant type
capsule
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Stability at restStability at rest
• Adhesion/cohesion.
• Suction cup.
• Limited joint volume.
• Inferior subluxation with
– hemarthrosis
– joint effusion
– surgical incision
– fluid
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Superior stabilitySuperior stability
• The same mechanisms as mentioned
before.
• Ceiling effect provided by superior cuff
tendon.
– Interposed between humeral head and
coracoacromial arch.
• Dependant on intact coracoacromial arch.
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Types of GH instabilityTypes of GH instability
• Circumstances of instability
– Congenital, chronic locked, recurrent,
traumatic, atraumatic, voluntary.
• Degree of instability
– Dislocation, subluxation
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Types of GH instabilityTypes of GH instability
• Direction of instability
– Anterior dislocations
• Fracture of the greater tuberosity, rotator cuff
avulsion, capsulolabral tears
• neurological, vascular and pulmonary
complications can occur
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• Direction of instability
– Posterior dislocations.
• Easily missed in 60% to 79% of cases.
• Mechanism is axial loading of adducted and
internally rotated arm.
• Proper physical examination.
Types of GH instabilityTypes of GH instability
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Types of GH instabilityTypes of GH instability
• Direction of instability– Inferior dislocations
• Hyper adduction force.
• Humerus locked in 110 to 160 degrees abduction.
• Severe soft tissue injury and fracture of proximal humerus.
– Superior dislocations
• Extreme forward and upward force on an adducted arm.
• Extreme soft tissue damage to cuff biceps tendon and other
muscles.
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Types of GH instabilityTypes of GH instability
• Bilateral dislocations
– Convulsions
– Violent trauma.
– Electric shock
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Clinical findingsClinical findings
• History
– Injury with arm in extension, abduction and
external rotation favors anterior dislocation.
– Electric shock, seizures or fall on flexed and
adducted arm favors posterior dislocation.
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Clinical findingsClinical findings
• Physical examination of anterior dislocated
shoulder
– Head palpable anteriorly.
– Hollow beneath acromion.
– Arm held in slight abduction and external
rotation.
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Clinical findingsClinical findings
• Physical examination of posteriordislocated shoulder– Lack of striking deformity
– Shoulder held in abduction and internal rotation
– Limited external rotation and elevation
– Posterior prominence and rounding of shoulder
– Flattening of anterior aspect of shoulder
– Prominence of coracoid process on dislocated side.
– Long standing cases• Muscle atrophy
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Clinical findingsClinical findings
• Radio graphic evaluation
– Demonstrate direction of dislocation.
– Associated fractures.
– Barriers to relocation.
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Clinical findingsClinical findings
• Radio graphic
evaluation
– Note views oriented to
scapula.
• Antero posterior view in
plain of scapula.
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Clinical findingsClinical findings
• Radio graphic
evaluation
– Note views oriented to
scapula.
• Scapular lateral view.
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Clinical findingsClinical findings
• Radio graphic
evaluation
– Note views oriented to
scapula.
• Axillary view.
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RadiographsRadiographs
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Clinical findingsClinical findings
• CT scan
– Greater detail
– Anterior inferior glenoid lesions
– Posterior lateral humeral head lesions
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation• Ligaments and
capsule
• Fractures
• Cuff tears
• Vascular injuries
• Nerve injuries
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Ligaments and capsule
– Antero inferior glenohumeral ligaments
from glenoid
• younger individuals.
– Non-healing
• recurrent traumatic instability.
– Capsule sometimes avulse from
anteroinferior portion humerus neck.
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Fractures
– Glenoid
– Humeral head
– Tuberosities
– Humeral neck fracture during attempted
closed reduction.
– Coracoid process
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Cuff tears
– Patients older than forty years
– Ultrasonography, arthrography, MRI
– Prompt repair
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Vascular injuries
– Elderly
• more fragile vessels.
– Axillary artery or vein or its branched avulsed.
– Erect dislocation.
– During reduction and chronic anterior
dislocation in the elderly.
– Mortality 50%.
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Vascular injuries
– Pain, expanding hematoma, pulse deficit,
peripheral cyanosis, peripheral coolness,
pallor, neurological dysfunction, shock.
– Doppler or arteriogram.
– Surgical emergency
– Digital pressure on artery over first rib
– Subclavicular operative approach.
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Associated injuries Associated injuries –– anterior anterior
dislocationdislocation
• Nerve injuries
– Mechanism is traction or pressure on
nerve.
– Incidence 33%.
– Different degrees of injury.
– Weakness and/or numbness.
– Most recover completely.
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Recurrence of instability after Recurrence of instability after
anterior dislocationanterior dislocation
• Age under 20yrs 33% to 90% chance
• age 20 to 30yrs 25% chance
• age 30 to 40yrs 10% chance.
• Higher chance in athletes and men
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Recurrence of instability after Recurrence of instability after
anterior dislocationanterior dislocation
• Effects of post dislocation treatment.
– General consensus on immobilization over
three weeks.
– In physically demanding sport or
occupation
• aggressive post dislocation rehabilitation
program is necessary.
– Return to activities
• no weakness, atrophy or apprehension is
present.
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Associated injuriesAssociated injuries--posterior posterior
dislocationdislocation
• Fractures
– Posterior glenoid rim.
– Lesser tuberosity.
– Proximal humeral multi part.
• Other associated injuries
– Rotator cuff and neurovascular injuries.
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Treatment of acute traumatic Treatment of acute traumatic
anterior dislocationanterior dislocation
• Timing of reduction and analgesia
– Complete set of radio graphs.
– Rule out associated bony injuries.
– Early reduction.
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Treatment of acute traumatic Treatment of acute traumatic
anterior dislocationanterior dislocation
• Method of reduction
– Without use of medication• Acutely.
– Narcotics and muscle relaxant.• Respiratory depression.
• Resuscitation equipment.
– General anesthesia, brachial plexus block • longstanding locked dislocation.
– Intra articular Lignocaine 20ml.
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Treatment of acute traumatic Treatment of acute traumatic
anterior dislocationanterior dislocation
• Method of reduction
– Traction on abducted + flexed arm with
counter traction on thorax.
– Elbow flexed 90 degrees
• relax neurovascular structures.
– Steady traction on long axis of arm.
– Outward pressure on proximal end of
humerus.
– Post reduction x-rays.
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Treatment of acute traumatic Treatment of acute traumatic
anterior dislocationanterior dislocation
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Chronic anterior traumatic Chronic anterior traumatic
dislocationsdislocations
• Reduction and analgesia
– Dislocated for several days.
– Difficulties and complications with reduction.
– Commonly in elderly people or altered mental
status.
– Soft bone.
– Humeral head firmly impaled on glenoid.
– Careful for Kocher maneuver.
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Chronic anterior traumatic Chronic anterior traumatic
dislocationsdislocations
• Open reduction
– Altered position neurovascular structures
– Structures tight and scarred.
– Head collapse.
• Humeral head prosthesis.
• Results of treatment of chronic dislocation
– Closed reduction success rate 50%.
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Management after reduction of Management after reduction of
anterior dislocationanterior dislocation
• Evaluation
– AP and lateral x-rays
– Neurological status
– Strength of pulse
– Bruits and expanding hematoma
– Rotator cuff integrity
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Management after reduction of Management after reduction of
anterior dislocationanterior dislocation
• Protection
– Flexion to 90 degrees.
– External rotation to 0 degrees
– Three weeks.
– Cuff and deltoid isometrics
– Duration of immobilization reduced with
increasing age.
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Management after reduction of Management after reduction of
anterior dislocationanterior dislocation
• Strengthening
– Patient is informed.
– Cuff strengthening.
– Scapula stabilizing strengthening.
– More effective anterior atraumatic subluxation
and posterior instability.
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Indications for early surgeryIndications for early surgery
• Soft tissue (ruptured cuff)
• Displaced fracture of greater tuberosity
– Superior and posterior displacement on AP radiograph.
• Glenoid rim fracture
– Incongruity and inadequate glenoid arch
• Special problems
– High demand work or sports.
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Posterior dislocationsPosterior dislocations
• Reduction
– Supine position.
– Longitudinal and lateral traction.
– Head lifted anteriorly.
– Open reduction through deltopectoral
approach.
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Posterior dislocationsPosterior dislocations
• Post reduction care– Sling immobilization.
– Brace in abduction, external rotation and extension in unstable cases.
• Early surgery– Tuberosity fracture.
– Glenoid rim fracture.
– Irreducible dislocation.
– Open dislocation.
– Unstable reduction.
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Posterior dislocationsPosterior dislocations
• Chronic posterior dislocations
– ? Surgery in older patient.
– Sometimes there is a tuberosity transfer or
arthroplasty.
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Recurrent instabilityRecurrent instability
• Recurrent atraumatic instability
– Minimal trauma.
– No humeral head defect.
– No tuberosity fracture.
– No glenoid lip fracture.
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Recurrent instabilityRecurrent instability
• Recurrent atraumatic instability
– Thin compliant capsule.
– Flat glenoid fossa.
– Poor neuromuscular control.
– Poor humeral head centering.
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Recurrent atraumatic instabilityRecurrent atraumatic instability
• Loss of midrange stability
• Multi directional
• Many factors may be developmental
– Likely to be bilateral and familial
• AMBRII
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Recurrent atraumatic instabilityRecurrent atraumatic instability
• Discomfort and dysfunction.
• ADL
• Minor injury or period of disuse may be
present.
• Reduces spontaneously.
• Progressively easy development of
symptoms.
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Recurrent atraumatic instabilityRecurrent atraumatic instability
• Physical examination.
– Patient demonstrate jerk test and inferior
subluxation.
– Laxity test.
– Stability tests.
– Strength tests.
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Recurrent atraumatic instabilityRecurrent atraumatic instability
• Radiographs
– Usually no bony pathology.
– Sometimes translation of humeral head on
glenoid.
– Hypo plastic or dysplastic glenoid.
• Arthroscopy
– Drive through sign.
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Recurrent traumatic instabilityRecurrent traumatic instability
• Injury of sufficient magnitude.
• Determine definition of original injury.
• Inquire subsequent episodes of instability.
• Problems throwing overhand, sleeping,
hand behind head, lifting bucket of water.
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Recurrent traumatic instabilityRecurrent traumatic instability
• 14 to 34yrs
– glenoid labrum, glenoid rim and postero
lateral humeral head.
• Older than 35yrs
– greater tuberosity displaced and rotator cuff
(subscapularis).
• TUBS
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Recurrent traumatic instabilityRecurrent traumatic instability
• Apprehension test
confirm impression
obtained from
history.
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Recurrent traumatic instabilityRecurrent traumatic instability
• Pain relieves with
relocation.
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Recurrent traumatic instabilityRecurrent traumatic instability
• Radiographs
– Look for head and glenoid defects.
– CT scans for bony defects.
– MR arthrography for labrum, ligament and
rotator cuff injury.
• Electromyography
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Recurrent traumatic instabilityRecurrent traumatic instability
• Arthroscopy
– Classification of anterior labrum Bankhart
lesions.
– Definition of type of lesion.
– Diagnosis of SLAP lesions.
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Recurrent instability treatmentRecurrent instability treatment
• Non operative
– Strong muscle contraction
• Stabilize humeral head in glenoid (mass effect)
– Strong muscle action
• Centralize humeral head on glenoid.
– Optimal neuromuscular control
• Rotator cuff, deltoid, pectoralis and scapular
muscles.
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Recurrent instability treatmentRecurrent instability treatment
• Non operative
– Of particular benefit
• AMBRI
• Children
• voluntary instability
• posterior instability
• supranormal range required like gymnasts
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Operative management Operative management
traumatic anterior instabilitytraumatic anterior instability
• Where original anatomy has been
disrupted
• Redislocation most likely
– Reduced glenoid depth and width.
• Procedures
– Capsular labral reconstruction.
– Coracoid transfer.
– Open or Arthroscopic.
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Operative management of Operative management of
posterior posterior instabliltyinstablilty
• Multifactorial and complex
• Posterior soft tissue repairs.
• Rotational osteotomy of humerus.
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Operative treatment of Operative treatment of
atraumatic instabilityatraumatic instability
• Concavity compression optimized
– Muscle strengthening and neuromuscular control.
• Mechanical problem must be identified.
• Surgery
– Deepening the glenoid through capsulolabralreconstruction
• Open and arthroscopic techniques.
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Operative treatment of Operative treatment of
atraumatic instabilityatraumatic instability
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Operative treatment of Operative treatment of
atraumatic instabilityatraumatic instability
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Operative treatment of Operative treatment of
atraumatic instabilityatraumatic instability
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Superior Superior labrallabral lesions (SLAP)lesions (SLAP)
• Fall on outstretched hand with humeral
head compression over labrum.
• Deceleration injury with sudden pull on
LHB.
• Pain with stress on LHB.
• MR arthrography.
• Arthroscopic repair.
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Superior Superior labrallabral lesions (SLAP)lesions (SLAP)
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Superior Superior labrallabral lesions (SLAP)lesions (SLAP)