Mr. T P SelvanMB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho)

Consultant Orthopaedic SurgeonEast Surrey Hospital

Redhill

Anatomy Diagnostic clues Examination Investigations (X-ray indications) Injection- indications & techniques Referral to Orthopaedic Specialist Red flag signs Surgical procedures performed

AGE 10-35 yrs Instability

30-50 yrs AC joint disease

40-60 yrs Frozen Shoulder

>60 yrs GH arthritiis

35-75 yrs Rotator cuff disease

HISTORY Pain on overhead activities Impingement

Night Pain Rotator cuff disease, GH arthritis,Frozen shoulder

Dead arm Instabiltiy

Trauma Rotator cuff tear, Fracture

LOCATION OF PAIN

Rotator cuff disease

1. Under deltoid

2. Side of arm

3. Front of arm

Pain in the shoulder

blade area (location 4) is usually muscular or nerve related

Wasting of supraspinous and infraspinous fossae Long head of biceps

rupture

SUPRACLAVICULAR FOSSA

NEUROLOGICAL EXAMINATION

VASCULAR EXAMINATION

CERVICAL SPONDYLOSIS

CERVICAL SPINE FRACTURE AND TUMOUR

ACTIVE/PASSIVE

DELTOID FUNCTION SUPRASPINATUS FUNCTION TERES MINOR/INFRASPINATUS FUNCTION DROP SIGN SUBSCAPULARIS FUNCTION 1. GERBER’S LIFT OFF TEST 2. NAPOLEON’S BELLY PRESS TEST BICEPS TENDON 1. YERGASSON’S TEST 2. SPEED’S TEST

Abduction in scapular plane

ELBOW AT 90 DEGREES

Ext. Rotation against resistance

GERBER’S LIFT OFF TEST

BELLY PRESS (NAPOLEON’S) TEST

SPEED’S TEST

NEER’S IMPINGEMENT TEST

GREAT CAUTION! IN YOUNG PATIENTS CLOSELY EVALUATE FOR SIGNS OF INSTABILITY, THE MOST LIKELY CAUSE OF IMPINGEMENT

Why do we need X-rays?

Frozen Shoulder to exclude other pathology

Rotator cuff disease◦ Impingement Sclerosis GT and Acromion◦ Cuff tear Superior migration of

humerus(+/-)◦ Cuff arthropathy Humero-acromial articulation

Instability Hill Sachs lesion

Glenohumeral OA AC joint dislocation / OA

ACJ arthritis Acromial spur

OSTEO ARTHRITIS

ROTATOR CUFF ARTHROPATHY

PATHOLOGICAL FRACTURE

CALCIFICATION

Ultrasound (one stop clinic)

MRI Arthrogram CT Scan EMG Bone Scan ARTHROSCOPY

Rest

NSAIDs / Analgesia

Physiotherapy

Steroid Injection

Indications for Injection Diagnostic

Subacromial impingement Acromioclavicular joint pain Aspiration

Therapeutic Subacromial impingement Rotator cuff tendinitis / Bursitis Calcific tendinitis Glenohumeral OA Long head of biceps tendinitis Frozen Shoulder AC joint arthritis

a) Subacromial spaceb) Glenohumeral joint

Subacromial space

Palpate the posterolateral corner of acromion

1-2 cm below and medial to point

Needle directed towards the coracoid process

Glenohumeral joint

Palpate the coracoid process

1-2 cm below and lateral to point

Needle directed towards the joint

Failure of conservative treatment for 6 months

Signs & Symptoms of INSTABILITY Suspected ACUTE ROTATOR CUFF TEAR Uncertain diagnosis Red flags

Infection : red hot skin, pyrexial, systemically unwell

Unreduced dislocation: h/o trauma/fit/electric shock, abnormal contour, loss of movements

Acute rotator cuff tear: acute onset pain and weakness, recent trauma, drop arm sign

Tumour: S/S of cancer, h/o cancer, abnormal mass, swelling or deformity

Neurological: severe sensori-motor deficit, unexplained muscle wasting.

Subacromial Impingement

Subacromial decompression

RECONSTRUCTIVEANTERIOR STABILISATION

Surface replacement Total shoulder replacement

Reverse Delta Shoulder replacement