Shoulder Pazourek, L., Rozkydal, Z. SHG2.jpg 5 joints —Glenohumeral —Acromioclavicular (AC) —Sternoclavicular (SC) —Thoracoscapular —Bursal joint — + connection to Th and C spine — — — SHG3.jpg SHG4.png https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcTCqigqi7I_LW5g02HfviL41nbOQaTj6zQo1xLNKyGqwjW 2ZOW4JA http://www.t-nation.com/img/photos/06-074-training/image003.png stab3.jpg Stability of GH joint —Biggest ROM — — small glenoid — —Soft tissue stability —Static: labrum glenoidale, capsule, glenohumeral ligaments —Dynamic: muscles of rotator cuff — deltoid muscle — —Patology: —Most frequent dislocation —Instability- often — — — stab1.jpg stab2.jpg stab3.jpg Subacromial joint —Impingement syndrom — —Subacromial bursa — — — Imping Imping http://4.bp.blogspot.com/-C7cBa-Vg9Rw/UiowJBoRfjI/AAAAAAAAD04/kLd9j65-tog/s1600/CTA%20AP.jpg Rotator cuff —m.subscapularis, m.supraspinatus, m.infraspinatus, m.teres minor — —Movement in GH joint —Depression of the humeral head —Dynamic stabilisation — — http://www.ericcressey.com/wp-content/uploads/2012/01/kirs-f02.jpg http://www.t-nation.com/img/photos/07-016-training/image008.jpg Long head of biceps LCMBB —intraarticular — —Insertion to upper portion of labrum — —Pathology: —tenosynovialitis —Rupture —SLAP http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/biceps-brachi i/atlasImage Rameno- rpt http://orthopaedic.com.sg/wp-content/uploads/2011/05/Snyders-SLAP-Tear-Classification.jpg Slap Tear GH joint —Primary O.A. less frequent — —Posttraumatic —R.A. —Rotator artropathy —Necrosis of humeral head http://www.zadeh.co.uk/shouldersurgery/copeland_1.jpg http://img.medscape.com/pi/emed/ckb/radiology/336139-401595-4612tn.jpg http://images.radiopaedia.org/images/130249/4d542c80cc49dfee526b7d9cf79083.jpg Figure 1: X-ray (anteroposterior view) left proximal humerus in a 61-year-old man showing (a) 3 part proximal humerus fracture; (b) postoperative X-rays with well alligned fragments and k-wires in situ; (c) X-rays at 5 years followup with well healed and remodeled proximal humerus Analysis of pain — —impingement syndrom –painful arc —Pain in full elevation– AC joint —Pain in abduction 20-30 degree- supraspinatus • • Pain in rest or during night – pyogenic arthritis, O.A., R.A. acute rpt of RC, acute tendinitis • Pain iradiating to the shoulder painfularc1.jpg Clinical examination — — —Deformity of the spine —Muscle dysbalance —scapula alta -Sprengel —Palsy of n. thoracicus longus (m.serrarus anterior) —Palsy of n. accesorius (m.trapezius) — http://cfile234.uf.daum.net/image/18602E4C4D391D88138CB7 06 http://www.ijoonline.com/articles/2011/45/2/images/IndianJOrthop_2011_45_2_132_77132_f7.jpg http://www.shoulderdoc.co.uk/images/uploaded/wing02a.jpg feature image Clinical examination —Muscles —Antalgic position —Swelling —Skin — https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcR1eQLZbE0rOUaI5AW3DlSR9XBGtHScTmBL5bZH1DD4Erl hOcdpbQ http://www.backandneck.ca/wp-content/uploads/2012/09/right-shoulder-pain-causes.jpg https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTLSU5mcz0xXsSAWsgsyy5zs3HL0PBncvmKDlZhS449N5M EDiwY Clinical examination- tenderness http://www.maitrise-orthop.com/photos/168/cdumontier_doursounian_miseaupoint_1010/fig8dumontier.jpg http://www.athletestreatingathletes.com/wordpress/wp-content/uploads/2010/10/postshouldbone.jpg http://ajs.sagepub.com/content/35/8/1334/F1.large.jpg image https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcREGOto5Xwg1xGfOOik9aK8-8ps8HqKFOJEq4NsPf8uO_6 dngjs [USEMAP] palp.png http://www.aafp.org/afp/2000/0515/afp20000515p3079-f2.jpg http://classconnection.s3.amazonaws.com/184/flashcards/1904184/jpg/11353983319351.jpg ROM —SFTR — http://classconnection.s3.amazonaws.com/184/flashcards/1904184/jpg/11353983319351.jpg 9.png 8.jpg Clinical examination – stability — —Posttraumatic instability — (typicky unidirekcionální, přední) —přední zásuvka —Apperhension test —Jobeho relokační test —event. zadní zásuvka, zadní Apperhension test (u zadní instability) —Habitual instability —příznaky mesenchymální laxicity —sulcus sign —známky multidirekcionální instability — http://classconnection.s3.amazonaws.com/693/flashcards/1000693/jpg/img_02661359054155732.jpg H:\Výuka\Nová složka\laxita3.jpg Rotator cuff tests —Resistance tests — — m.supraspinatus: —Abduction —Jobe test —drop arm test —M. infraspinatus, teres minor —External rotation — —m.subscapularis —Inner rotation —Gerber test —Napoleon sign (press belly test) — ss1.png ss2.png is1.png is2.jpg https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTGDTm4CnBtfQAaEBTCpEt3e-0PAi4Mkk2fQUKoPkcUqft OytY7 sub1.jpg painfularc1.jpg Impingement syndrom —Painfuil arc (60 – 120 degree) —crepitation —impingement sign Neer —impingement sign Hawkins and Kennedy —Neer infiltration test — https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRShVEjfZJgFW25BkjCJaWEzH4cGzjR4c7qPY2ioR3UAG9 wLV4BSw imp.png https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcQ0_p7SpyfUs3_UvNEdi7_ychjeAPM-XeZSloAdq9r3PPI fiOclvw Tests for CLMBB —Tenderness —Speed test —Yergasson test —Distalisation of muscle belly 7.jpg 6.jpg bic1.png Rameno- rpt Tests for AC joint —tenderness —painful full elevation —Dislocation of clavicle painfularc1.jpg 10.png 11.jpg ac1.png C:\Users\Lukas\Desktop\x\punction.jpg Imaging —Ultrasonography —X-ray — —CT — —MRI — —Others — — https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcTFCYkw5g_SBQ36eLGdjCiT5MYCFyK3IOD_oV9CS5yovbx hMF0z GrasheyView.gif https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcQvTBd9CBUpb3WVGsORuFKDBeulfzqGaas9ew8KHbd1N-6 Y7-TYUA Ultrasonography —USG http://images.radiopaedia.org/images/634504/928082065c2c73d636e1ff77dcaccc.jpg —impingement syndrom —SA bursa —RC —Changes in USG D:\Sono\sonoObr\burz subakr\12.jpg D:\Sono\sonoObr\kalcif RM\1.jpg X ray —ap —axial —inferoposterior —transthoracal —Y projection — ap.jpg http://www.imageinterpretation.co.uk/images/shoulder/GLENOID3%20AXIAL.jpg http://4.bp.blogspot.com/-_yYTBrH9qqw/T4qi7X0dWAI/AAAAAAAAAU8/Q9lhJbM37f8/s1600/lawrence+radiograph +transthoracic+lateral.png Y2.jpg Xray —X ray https://www.jaaos.org/content/17/9/582/F1.large.jpg D:\artróza\rameno\image1.jpg https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTI1tsUsddgCA-l2WacYTfSgkkB7umpjiOQeRtGh71JTRX RQAhcXQ D:\Xrameno\RTG\OA s nekr.jpg D:\Xrameno\RTG\OSA.jpg KuželaMiroslav46RTGhumL.jpg X ray —instability (Hill Sachs defect —Subacromial space D:\Xrameno\RTG\snížení SA prostoru.jpg ac1.png D:\Xrameno\RTG\kalcifikace1.jpg HS.png http://theses.ulaval.ca/archimede/fichiers/24646/24646_14.png D:\Xrameno\RTG\rot artropat.jpg CT —CT BonyBankart.jpg BonyBankart2.jpg OA s nekr2.jpg MRI —Soft tissue http://seattleclouds.com/myapplications/Albertosh/Shoulder/BANKART2.jpg https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcR8US_TOXQMKh57LB_DoArFpw1ZwW2tWcX7kM2NPkWCGXE eYXPJ http://img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1256857-536tn.jpg Painful shoulder Tenosynovitis of tendon of long head of biceps Rupture of tendon of long head of biceps Subacromial bursitis Supraspinatus tendinitis Rotator cuff rupture Impimgement syndrom Frozen shoulder syndrom Osteoarthritis of glenohumeral joint Disorders of acromioclavicular joint Inflammations Tumors Referred pain from cervical spine Tenosynovitis of long head of biceps Tenderness Resisted flexion and supination of the elbow Therapy: Corticosteroids locally Rest, sling NSAID Entezo- biceps Rupture of long head of biceps Rameno- rpt bicepsu Therapy: Rest, sling NSAID Surgery – up to 40 years Conservative- over 40 years Surgery: key hole fixation to the humerus Suture to the short head of biceps Rupture of long head of biceps Rameno- rpt Tenderness Distalisation of muscle belly Diminished strength Subacromialis bursitis Inflammation White fluid Severe, burning pain Restricted movements Tenderness Calcifications Rameno- bursitis subac Rameno-kalcifikace v burze Conservative treatment: Rest, sling Lavage with 2 needles Corticosteroids locally NSAID Physiotherapy Surgery: Removal of bursa Subacromial bursitis Rameno- bursitis Bursitis subacromialis •Therapy Rameno- bursitis subac 1.Conservative 2.Surgery http://www.emedx.com/emedx/diagnosis_information/diagnosis_information_image_files/shoulder_images/ subacromial_bursitis_arthroscopic_picture-1.jpg shawer.png http://sitemaker.umich.edu/fm_gmeig_musculoskeletal_joint-inject-aspir/files/subacromial_bursa_inje ction.jpg Supraspinatus tendinitis Tenderness over greater tuberosity Limited movements Therapy: Rest, NSAID Corticosteroids Physiotherapy Rameno-rpt Rotator cuff Rotator cuff: m. supraspinatus m. infraspinatus m. teres minor m. subscapularis Function: First 30 ° of abduction Pressure of the humeral head into glenoid cavity Depressor of the humeral head Entezo- RM Rameno- anatomie 2 Anatomy of the shoulder Entezo- rameno ze zadu Anatomy of the shoulder Rameno Rupture of rotator cuff Rameno- rpt Partial rupture: Severe pain Painful arc Painful abduction Keeps the arm in position of adjusted abduction Ultrasonography Management: conservative RC •Tendinopathy • Degenerative rupture • Rotator arthropathy RM6.png https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcSoPXtETbFyAgCdPpTRoIoN8mOZsabBPLrwcXIwEq7kND- uhk9q RM7.png RM3.jpg RC •Suture of RC • reverse total joint arthroplasty RM1.jpg RM2.png RM4.png Completed rotator cuff repair Rupture of rotator cuff Rameno- rpt Complete rupture: No active abduction Lifting of the shoulder Managemet: suture: ASC, open surgery - attachment to greater tuberosity Completed rotator cuff repair Impingement syndrom Greater tuberosity impinges to distal surface of acromion and coracoacromial ligament Narrowing of subacromial space Imping Impingement syndrom Imping Imping Causes • acromion spur •Change of acromion •Distal osteophytes of AC •Prominence of tuberculum maius Impingement syndrom Stages: 1.Swelling, hemorhage of supraspinatus 2. Fibrosis, tendinitis, bursitis degenerative changes of cuff 3. Rupture od rotator cuff and long biceps tendon Entezo- GH kloub Impingement syndrom Rameno-bolestivý oblouk Symptoms: Painful arc Impingement sign Impingement test Jobe test X-ray: Narrowed subacromial space Y view- outlet view Arthrography Ultrasonography Impingement syndrom Therapy: 1.stage: conservative Rest, NSAID, Physiotherapy, Local corticosteroids 2. stage: the same + bursectomy, ASAD 3. stage: ASAD Subacromial decompression Burr acromioplasty Frozen shoulder- capsulitis adhesiva Rameno- sy zmrzlého ramene Progressive limitation of movements Pain No motivation for movement Shrinkage of capsule Adhesions in distal recesus Tightening of soft tissue Muscle spasm Low capacity of joint space The cause All conditions limiting joint movements: Impingement syndrom Arthrosis of AC joint Posttraumatic conditions Inflammations Thoralic outlet syndrom Tumors of the lungs Disorders of pleura Cardiac disorders Rameno- frozen shoulder Frozen shoulder Management: Long lasting period Heat Passive movements Positioning Active movements Physioterapy NSAID Local corticosteroids ASC- decompression Redressement force Removal of adhesions Rameno- frozen shoulder Long head of biceps Tenosynovitis in SLAP lesion • subluxation • parcial or total rupture • Th.: • conservative • ASC debridement • Tenotomy, tenodesis http://ajs.sagepub.com/content/38/8/1584/F1.large.jpg http://cdn5.arthrex.com/taxon-images/proximal_biceps_tenodesis/proximal_biceps_tenodesis_0-large.pn g SLAP lesion —= superior labrum anterior, posterior — —Causes —Subluxation, dislocation —Microtraumatisation —throwing shoulder — —Snyder classification Instability of GH joint —Acute, chronic posttraumatic —Multidirectional, unidirectional —Habitual —Posterior, anterior —Neglected — — —History C:\Users\Lukas\Desktop\stabilizace1.png stab.png http://www.shoulderinformation.com/pics/bankartsutures.jpg Glenohumeral osteoarthritis - omarthrosis Rameno- artróza Therapy: Conservative Total shoulder replacement Osteoarthritis —Secondary —Postraumatic —In R.A. —Rotaror arthropathy —Primary —Therapy —Conservative —surgery —Resurfacing —Head prosthesis —Total joint —Reverse total joint H:\artróza\rameno\image3.jpg H:\artróza\rameno\image1.jpg http://www.lima.it/repository/fck/image/Special%20edition%20usa%202012/protesi-smr-america.jpg http://t0.gstatic.com/images?q=tbn:ANd9GcR86hkV-dSijXNJhhDoiEkSscowz_r-a-raSAAC9HT_Szpm5ZV- http://t2.gstatic.com/images?q=tbn:ANd9GcTnZXQXRGTjfKlpMUxlJ5XiMtj25NQaju-XaXOoBI9tfsrAs2jt http://cz.all.biz/img/cz/catalog/27710.jpeg Rotator arthropathy — poperační předoperační Reverse total shoulder artroplasty Infection and tumors —Pyogenic arthritis — —Tumors —OSA, CHoSA, Ewing- sa —Metastases —Benign tumors —Myeloma KuželaMiroslav46RTGhumL.jpg Disorders of acromioclavicular joint Synovitis O.A. Sprain Subluxation Dislocations Rameno- luxace AC Refered pain to the shoulder Cervical spine Thoracic outlet syndrom Cardiac diseases Lung and pleura disorders Herpes zoster neuralgia