The aim is to understand the anatomy and function of shoulder joint and to be able to explain the diagnosis and treatment of common problems or diseases around the shoulder such as rotator cuff syndrome dislocation and fractures of shoulder joint and also to appreciate the differences between adults and children in trauma involving the shoulder and elbow joint
ANATOMY AND FUNCTION
Functionally. this is a complex of joints between the humerus. scapula. clavicle. manubrium and the chest wall. Its role is to enable the hand to be placed in as many positions and orientations in space as possible. The elbow and wrist work with the shoulder to achieve this. of all the joints in the body, the shoulder probably offers the greatest range of movement.
The clavicle acts as a spoke or strut to hold the glenohumeral joint away from the chest wall. The sternoclavicular joint acts as a hub around which the shoulder girdle can move, the scapula moving freely around the posterior chest wall controlled by muscles such as serratus anterior, the rhomboids and trapezius. The glenohumeral joint is an open ball and socket in which sta bility is provided to a large degree by the short rotators of the shoulder. These are the supraspinatus, infraspinatus and subscapularis,all of which insert into the rotator cuff,which provides the joint with a strong but dynamic enclosure. Finally,there are strong motors which pass directly from the axial skeleton to the arm and which power and control the upper limb. These are the pectoral muscles, latissimusdorsi and the teres muscles. Running immediately beneath the shoulder joint is the neurovascular bundle, which is susceptible to injury from trauma to the shoulder, or surgery to the breast or lymph nodes draining the arm.
HISTORY AND EXAMINATION
The principles of history and examination are laid out in section of clinical examination but revolve. round pain, deformity and loss of function.
Because the shoulder and elbow serve the hand, functional problems experienced by the patient may frequently be with the hand.
Summary of the function of the shoulder and elbow
• To serve the hand, enabling it to be put in many places and many orientations
• The design reflects a compromise between mobility,stability and strength
CONGENITAL ABNORMALITIES OF SHOULDER JOINT
This is the most common congenital abnormality around the shoulder, and results from a failure of normal descent of the scapula. In the embryo. the scapula forms in the midcervical region, and then descends to its midthoracic position. With the Sprengel deformity,the scapula is high, small and rotated, and in approximately50% of cases the scapula is connected to the cervical spine by the omovertebral body,a fibrous or bony bar. In addition, there may be other congenital deformities.which include rib abnormalities, scoliosis of the thoracic spine or cervical spine abnormalities including the Klippel-Feil syndrome congenital fusion of the cervical vertebrae.
The major problem is usually cosmetic rather than functional. and this is particularly true for unilateral deformities. In these . cases excision of the omovertebral body or superior angle is performed Surgery is occasionally required to improve function, in these circumstances more complex reconstructive procedures are carried out.
The painful shoulder
Shoulder pain is the second most common musculoskeletal problem (back pain is the most common) seen by primary care physicans. The most common causes of painful shoulder in adults are disorders of the rotator cuff,particularly the supraspinatus tendon. Although conditions such as painful arc syndrome.impingement, rotator cuff tears and cuff tear arthritis are often considered as separate conditions, in reality they are part of a spectrum of disorders of the supraspinarus tendon. Other causes of shoulder pain include calcific tendonitis. frozen shoulder and degenerative disease.
• Second most common musculoskeletal complaint after backache
• Most painful conditions relate to disease of the suprospinatus tendon
Disorders of the rotator cuff
In common with some other tendons of the body. the supraspinatus tendon has a relatively poor blood supply.and this can predispose it to both degenerative changes and tearing of the tendon. The anterolateral portion of the tendon is initially affected. and swelling of this portion may lead to Impingement between the creater tuberosity of the humerus and the antenior acromion with its attached coracoacromial (CA) ligament. This leads to pain, particularly on active abduction or flexion, and initially leads to a painful arc between 60 and 120 degree.Abnormalites of the bone occur. with hooking of the anterior acromion.These are probably secondary changes. rather than the primary cause of the pain. but surgical treatment is often directed against the acromion and the CA ligament
History and examintion
The patient is usually middle-aged. and the initial symptoms may be the result of a specific traumatic incident. or of a period of overuse of the arm. However, there may be no precipitating events. The pain is activity related and worst when the arm is above the head. such as reaching up to shelves or hair washing. Some patients complain of significant weakness. and this may indicate the presence of a rotator cuff tear.
On examination. there is often no local tenderness. Active
movements may be limited. and usually reproduce the symptoms. which occur between 60 and 120 degree of abduction and flexion . There is usually much less pain on passive movement. and this confirms the mechanical nature of the pain. Weakness of both supraspinatus and infraspinatus may be found. This suggest the possibilityof a tear in the cuff. Specific impingement tests have been described and help to confirm the diagnosis . Radiographs may be normal. but there are usually signs of subacromial sclerosis.
Subacromial injection of local anaesthetic and cortisone often
leads to improvements in the symptoms. and they are used for both diagnostic and therapeutic purposes. If the diagnosis is correct, the symptoms are usually improved.The benefit may only be short lived. but this is a valuable diagnostic aid. Improvement in symptoms occurs for a few weeks after the injection, but subsequent relapse commonly occurs.
Summary of the supraspinatus problems
• Most common in the middle-aged
• Related to activity, especially if the arm is above the head
• No local tenderness
• Passive movement is less painful than active
• Local anaesthetic and/or cortisone injection into the subacromial region is diagnostic and therapeutic
A subacromial injection is the most useful diagnostic test, and this is easily performed in the out-patient clinic. Further investigations such as ultrasound and magnetic resonance imaging (MRI) are used to determine the presence of a tear of the rotator cuff if surgery is contemplated; they have little place in the diagnosis of impingement.
It is likely that most patients condition will settle with non operative treatment. The initial treatment is by cortisone injection, and this is repeated up to three times if there is prolonged relief of symptoms from each injection. Specific physiotherapy has a role, particularly in the early stages, but most patients who present to specialist clinics will only have a limited response. Surgery is eventually required in 50% of these patients, and is indicated when symptoms, sufficient to limit activities, have been present for over a year. Decompression of the rotator cuff is carried out, either arthroscopically or by an open procedure, with removal of the anterior overhang and division of the CA Ligament. In addition, repair of a rotator cuff tear may be required. In the absence of a rotator cuff tear, the prognosis is good .
Summary of treatment of subacromial irritation
• Non-operative treatment, including injections and physiotherapy normally works
• Surgery is indicated in 50% of patients if symptoms fail to settle after a year
• Surgery decompresses the rotator cuff
Patients with rotator cuff tears are usually slightly older than patients with impingement. Tearing of the supraspinatus muscles also starts at the front lateral edge of the tendon, and can progress posteriorly along the tendon, detaching it from the greater tuberosity. The tendon retracts medially leading to a U-shaped tear. The patient is usually unaware of the rotator cuff tearing, and large tears of several years duration may be present before the patient seeks medical attention .
Small tears of the supraspinatus
These are very common and may be found in up to 20% of the normal population, in the absence of any specific shoulder symptoms. The tear is usually less than 1 cm in length and, in the absence of significant pain, is not of a sufficient size to cause weakness of the shoulder.
Treatment of small tears Treatment is dependent on the presence and severity of impingement symptoms. In the absence of symptoms, the tear can be left unrepaired, and the patient kept under review. Progression of the tear is an indication for repair. It impingement is a significant problem, decompression is carried out, and the tear can be repaired if appropriate
tears of 2-3 cm (as measured by ultrasound) are usually associated with symptoms of impingement or weakness of the shoulder, these will often require decompression and repair of the supraspinatus. This can be carried out through a lateral sabre type incision. The tendon is mobilised, and then sutured into a bony trough created on the edge of the greater tuberosity, using osseous sutures. Results of repair are good for intermediate tears,but full recovery will take several months.
Large tears of the supraspinatus
These are often 5 cm or greater, and may extend into infraspinatus. They are usually associated with weakness of the shoulder, and abduction may be limited to 60 degree, often with a characteristic hunching of the shoulder . With massive tears of the rotator cuff, superior migration of the humeral head can occur, and this further impairs function. In addition, secondary osteoarthritis of the glenohumeral head may occur due to the resulting incongruity of the joint.
Treatment of large tears If symptoms of impingement or weakness are sufficiently bad, decompression and repair should be considered. Unfortunately repair is not always possible as the medial edge of the tendon retracts, and it may be impossible to mobilise this to close the defect. Tendon grafts and synthetic meshes have been used to close this defect but the results are less than satisfactory. This is due to degeneration and disuse atrophy of the supraspinatus associated with a chronic tear, and although the gap may have been closed there is poor function from the repaired tissue.
In many patients with large tears, the predominant symptom is
still pain rather than weakness, and in these patients, if the tear is irreparable by direct suture, simple decompression is carried out. Up to 80% of these patients will have good relief of symptoms and improved function, despite the unrepaired rotator cuff tear.
Acute tears of the rotator cuff
Most tears of the supraspinatus are due to degeneration and, as
discussed above, will be associated with impingement symptoms. Occasionally, a large tear of the rotator cuff can result from
trauma in the absence of any previous shoulder symptoms these patients present soon after the event with profound weakness and loss of function but minimal pain on examination there is
marked restriction of abduction, usually to less than 90 degree, with a characteristic hunching of the shoulder. This is due to elevation of and rotation of the scapula to attempt to aid abduction. Diagnosis is confirmed by ultrasound or MRI, and early exploration and repair is indicated. Unlike the large degenerate cuff tears, the acute tear is usually repairable if surgery is carried out early . Often no decompression is necessary, as the front edge ofthe acromion is normal with no evidence of overhang, In middle aged and elderly patients, an acute cuff tear can occur after shoulder dislocation.
Summary of the Tears of the rotator cuff
• Occur in an older age group
• Found in 20% of the normal population
• Treatment is required if the tear worsens
• Repair is more successful in the smaller tears
• Decompression will relieve pain and this may improve function
Summary of acute tears
• Present with little pain but profound weakness
• Early repair gives good results
This is a painful shoulder condition of unknown aetiology that affects the capsule of the shoulder. The rotator interval between supraspinatus and subscapularis is affected predominantly. The disease most commonly affects females in their 50 years, and is more common in diabetics and patients with heart or thyroid disease.
Summary of the frozen shoulder
• Aetiology unknown
• Sudden onset, sometimes following trauma very painful
• Usually in middle·aged women
• loss of external rotation is diagnostic
• Passes through painful, stiff then resolving phases
• Usually resolves spontaneously in 1-3 years
• Calcific tendonitis is a differential diagnosis
History and examination
The pain is often of sudden onset and may follow minor trauma. It is severe and often disturbs sleep, and fractures or joint infection may be considered in the differential diagnosis. In the early stages, the shoulder is difficult to examine owing to the pain, but as the disease progresses the range of motion is reduced, both actively and passively. Local tenderness is often felt anteriorly over the rotator interval. The pathognomonic sign of frozen shoulder is loss of external rotation and this differentiates it from rotator cuff disease. Plain radiographs exclude other intra-articular pathology.
The clinical course of frozen shoulder can be divided into three stages as follows
Stage 1 - the painful phase. This can last for 2-9 months. The shoulder becomes increasingly painful, especially at night, and the patient uses the arm less and less. The pain is often very severe, and may be unrelieved by simple analgesics.
Stage 2 - the stiffening phase. This can last for 4-12 months and is associated with a gradual reduction in the range of movement of the shoulder. The pain usually resolves during this period, although there is commonly still an ache, especially at the extremes of the reduced range of movement.
Stage 3 - the thawing phase. This lasts for a further 4-12 months and is associated with a gradual improvement in the range of motion.
The clinical course runs over a period ot 1-3 years, and usually resolves without any long-term sequelae,
Often, no treatment is required, and the condition will resolve as described above, The range of motion may be slightly reduced compared with the unaffected side, but the vast majority of patients have no functional problems.
Treatment in the acute stage is pain relief. Corticosteroids may be tried but have variable effects. Active and passive mobilisation can be carried out if comfort allows, but aggressive physiorherap: should be discouraged.
Surgery is usually reserved for prolonged stiffness affecting, function but can also produce good pain relief in the acute stage, Manipulation under anaesthetic may produce an increased range of motion. Arthroscopic distension of the joint with saline allows inspection of the shoulder before treatment. If these measures fail to produce any benefit, open release of the rotator interval can be carried out through an anterior approach.
This is a common disorder of unknown aetiology, which results m an acutely painful shoulder. Calcium is deposited within the supraspinatus, and it is thought that this may be part of a degenerative process. The differential diagnosis includes frozen shoulder, with both conditions occurring most commonly in middle-aged women.
History and examination
This pain is usually of rapid onset, often with no precipitating cause. In common with impingement, the pain is felt on the anterolateral aspect of the shoulder and is worse with activity particularly overhead activities. The pain can be very severe
and usually disturbs sleep. On examination. the shoulder tender anterolarerally, and there is often some restriction active, and sometimes passive, motion. External rotation will be possible and this differentiates the condition from frozen shoulder.
The calcific deposits can be seen on plain radiographs, within the supraspinatus tendon, inferior to the acromion and just medial to the tuberosity of the humerus. They can also be seen on ultrasound .
Simple analgesia should be tried. together with physiotherapy Calcific tendonitis usually responds to subacromial injection of corticosteroid. although a course of several injections may be necessary. The condition is often self-limiting, with resolution of symptoms and resorption of the calcium.
Resistant cases of calcific tendonitis are an indication for surgical treatment. Open excision of the calcific deposits can be carried out through a sabre incision, but arthroscopy of the shoulder with subacromial decompression is an alternative. The cuff can be debrided and, if the deposits are prominent, they can be removed through a smaller incision.
The prognosis for calcific tendonitis is generally good
Summary of the calcific tendonitis
• Common but of unknown aetiology
• Rapid onset, no cause, usually in middle aged women
• Calific deposits can be seen on plain radiographs
• The condition is self-limiting but may be helped by steroid injections
• Surgery is useful for resistant cases
Arthritis of the shoulder
The glenohumeral joint is commonly involved in inflammatory arthritis particularly rheumatoid arthritis (RA )with up to one thrid of these patients developing severe problems. Initially, the pain is related to synovitis, and this responds to medical management including intra-articular steroid injection.impingemem symptoms can also occur, either with or without rotator cuff tear. These Will respond to subacromial injection, decompression may be indicated. Arthroscopic synovectomy be carried out at the same time but, in general. open synovctomy is not indicated in the management of RA of the shoulder Chemical synovectomy may be indicated for symptoms that resistant to medical treatment, but this is not commonly performed for RA.
for advanced disease, glenohumeral arthroplasty is Indicated, with very good relief of pain. but there is often little Improvement he preoperative stiffness .
Summary of shoulder problems In rheumatoid arthritis
• Glenohumeral joint is involved in one·third of cases
• Impingement can lead to rotator ruff tears
• Synovectomy can be performed orthrscopically
• Joint replacement will improve pain but not range of movement
Osteoarthrins of the glenohumeral Joint is either primary or, more commonly, secondary. Secondary arthritis is usually due to previous trauma or to end-stage rotator cuff disease, in association with a massive tear of the cuff and superior migration of the humeral head.
As with osteoarthritis of other joints, medical measures are ini tially tried. Failure of medical management is an indication for surgery. Debridement of the joint and osteotomy have little, If any, place in the management of glenohumeral osteoarthritis, and joint replacement is the treatment of choice. Both total shoulder replacement and hemiarthroplasty, without glenoid replacement, can be carried out . Total shoulder replacement should only be carried out if the rotator cuff is intact. In most patients with RA, and all patients with cuff tear arthritis, the cuff is deficient, and hemiarthroplasty is therefore the most common replacement performed; this can be carried out through an anterior deltopecroral approach. Shoulder replacement is a very good pain-relieving procedure but, in general, will not restore movement to a stiff shoulder.
Arthrodesis of the joint is an alternative in the younger patient, especially if there is a history of sepsis, or any neurological problem that would affect the stability of a joint replacement . The peroperative morbidity is higher, however, and 3-4 months of immobilisation are required. The patient retains a surprisingly good range of movement at the shoulder and can function well owing to scapulothoracic movement .
Summary of the osteoarthritis of the shoulder
• Replcament of part of or the whole joint is the choice in sever cases
• If the rotator ruff is damaged, only hemiorthroplasty should be undertaken
• Pain will be relieved but stiff shoulder remain stiff
• Arthrodesis is an option in the younger patient
• Movement remains good because of the scapulothorooc joint
Arthritis of the acromioclavicular joint
Degenerative changes of the acromioclavicular (AC) Joint on plain radiographs are relatively common and are usually age related. Symptomatic disease, however, usually affects males in their 20-40s and is commonly due to a previous injury, It is often seen in individuals who play sport or are involved in an occupation that stresses the upper limbs. If inferior osteophytes are present. impingement on the underlying rotator cuff can occur.
History and examination
The pain is activity related and unlike most causes of shoulder pain. it is well localised, with the patient pointing to the AC joint as the source of the pain. On examination, there is usually a bony abnormality, with prominence of the distal end of the clavicle. This may be tender and movement of the joint by depressing the clavicle while pushing up the humerus will reproduce the pain. Flexing and adducting the arm to place the hand behind the opposite shoulder will also produce pain. An intra-articular injection of local anaesthetic will confirm the joint as the site of the pain. If the symptoms are related to the inferior osteophvtes, the pain is less localised, and Impingement signs and symptoms are present.
Intra-articular injection of corticosteroids will usually produce some benefit and a course of three injections may be tried. If
medical management fails, then surgery may be appropriate. the distal 0.5 to 1 cm of the clavicle is excised by a direct approach with good relief of pain and no functional difficulties. in patien with predominately impingement symptoms, arthroscoe debridement of the osteophytes can be carried Out
Summary of the problems of the acromioclavicular joint
• Usually secondary to trauma
• The resulting osteophyte can impinge on the rotator cuff
• Diagnosis is by injection of local anaesthetic
• Steroid injections may help • Excision of distal part of clavicl relieves the pain
Rupture of the biceps tendon
Rupture of the long head of biceps is a relatively common condition, occurring in middle age and in the elderly The condition closely related to rotator cuff disease and the tendon usually ruptures owing to chronic attrition. Although many patient present acutely, an asymptomatic biceps rupture is a relatively common finding during arthroscopy for rotator cuff surgery,
History and examination
The patient usually complains of something giving, often when they are lifting. The arm is often bruised and when the patient flexes the elbow a lump is evident in the middle of the bicep. The lump is initially tender and power is diminshed .
This condition is treated conservatively, and the patient can be reassured that the pain will ease and the power return, although this may take several months.
Rupture of the distal insertion of biceps is an uncommon condition that usually occurs in younger patients, particularly after a sporting injury. Again pain and weakness are present but, unlike rupture of the long head, the weakness will not Improve Surgical repair is indicated .
Summary of rupture of the biceps complex
• Proximal rupture is most common
• No surgery is needed
• Power returns but the lump remains
• Distal rupture needs repair if power is to be regained
Instability of the glenohumeral joint
Traumatic dislocation of the shoulder will be considered in the next section but recurrent instability is a common sequela of dislocation. Recurrent traumatic instability is age related, with over half of shoulder dislocations becoming recurrent in the under 25 year-olds, In some patients, the shoulder may dislocate after relatively little force, and a further group of patients with shoulder instability may be able to dislocate the shoulder at will. The diagnosis is based on an accurate history, and further investigations, other than plain radiographs, are not usually required.
There are many ways of classifying shoulder instability, based on direction and the degree of Violence required, as well as considering subluxarions and true dislocations. There is a spectrum of instability but, in general, three types of instability can be considered, a. follows .
Recurrent traumatic Instability
This is predominantly in one direction, most commonly antero
inferiorly. There is a definite traumatic event initially, although less violence is required subsequently.The patient is aware of apprehension during certain activities. and sport may be made difficult.The shoulder may sublux or dislocate. and often the dislocation has to be reduced under medical supervision.On examination. there is a full painless range of motion but apprehension on forced abduction and external rotation . Other joints are usually normal there is usually a Bankart defect, with detachment of the anterointerior glenoid labrum and damage to the humeral head .
Treatment Conservative treatment has little place and, if the
instability causes functional difficulties,surgery is indicated. for
anterior instability repair of the Bankart defect, in addition to some tightening of the capsule, will produce good results in90-95% of patients This is carried out through an anterior deltopectoral approach . for recurrent posterior instability (which is uncommon) tightening of the posterior capsule through a posterior approach is carried out. Summary of the types of dislocation
• Traumatic - unidirectional, responds well to surgery
• A traumatic- multidirectional, painful, responds to surgery Habitual-ligament laxity painless is not helped by surgery
Summary of the recurrent traumatic instability of the shoulder
• Usually anteroinferior
• Definite initial trauma
• Subsequently dislocations become easier
• Range of movement normal but apprehension sign positive
• Surgery involves repair of the torn labrum and tightening of the capsule
: A Traumatic instability
Although there may be an initiating event, this is often less traumatic, for example a fall climbing stairs rather than a sporting injury.In many cases there is no initial Injury, and the instability may occur in more than one direction. The shoulder usually subluxes rather than dislocates, and the patients can often reduce the shoulder him- or herself. The subluxation is painful, and the patient will not dislocate the shoulder at will. On examination, generalised ligament laxity is commonly present, and the shoulder can often be subluxed inferiorly to produce a sulcus sign, with a lateral sulcus appearing beneath the acromion as the arm is pulled down. Apprehension tests are again positive, but often in more than one direction.
Treatment Physiotherapy, by an experienced therapist, should be tried first in these patients. As well as muscle strengthening, reducation of the patient, and of the shoulder, is necessary, and specific muscle groups may need to be targeted.
Approximately half of the patients will require surgery, and a capsular tightening procedure is carried out through an anterior approach. This is a successful procedure but there is a higher failure rate than with patients found to have a Bankart defect. Arthroscopic shrinkage of the capsule may have a place in these patients; this is currently being evaluated.
This is a much smaller group of patients, but one which does not respond well to surgical treatment. The patient is able to sublux the shoulder at will and this is usually nor painful (Fig. 28.15). There is underlying joint laxity, which is usually generalised, and there is rarely a significant traumatic event. The patient may sublux the shoulder as a 'party trick', or for emotional or psychological reasons.
Treatment it is vital that these patients are assessed and managed by an experienced therapist. The patient must be educated to avoid subluxing the shoulder and shown exercises as appropriate. Surgery is associated with a high failure rate and should be avoided.